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Purpose: Extensive  intraperitoneal lavage (EIPL) is a novel therapeutic intervention that aims to limit the chance of peritoneal metastasis during gastrectomy. Clinical trials on using EIPL after gastrectomy show controversial results. We aimed to summarize the evidence of efficacy and safety for using EIPL after gastrectomy to limit the possibility of peritoneal metastasis and improve survival., Methods: A literature search on PubMed, Scopus, Embase, and Web of Sciences was conducted till June 2023 to identify eligible RCTs that assess the efficacy and safety of EIPL after gastrectomy. The hazard ratio with 95% CI was used to determine the survival probability, the risk ratio with 95% CI was used to assess the surgical outcomes, and ROB-2 and GRADE guidelines were used to assess the risk of bias and the certainty of evidence respectively., Results: Six eligible studies with a total of 1993 patients were included in the meta-analysis. Regarding survival benefits, the survival of the EIPL group did not differ significantly from the non-EIPL group, and the pooled HR of overall survival was 0.86 (95% CI 0.58-1.26) P = 0.44, the disease-free survival was 0.81 (0.58-1.13) P = 0.21, and peritoneal recurrence-free survival was 0.97 (0.79-1.2) P = 0.25. There is no significant association between EIPL and short-term postoperative outcomes. The use of EIPL does not appear to affect postoperative mortality, infection, anastomotic leakage, bleeding, ileus, or hospital stay., Conclusion: Our study yielded insufficient evidence about the survival benefits and surgical outcomes of EIPL in patients with gastric cancer after gastrectomy. Therefore, it is not recommended for treating gastric cancer patients., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Laparoscopic surgery offers many advantages compared to invasive surgery but one of the main problems is postoperative pain, partially resulting from the peritoneal inflammatory process mediated by inflammatory cytokines. The rationale of this study is that intraperitoneal washing could remove inflammatory mediators that are the cause of postoperative pain and could help in the removal of CO2 from the abdominal cavity. This article aims to analyze the effects of peritoneal lavage in the reduction of postoperative shoulder pain., Patients and Methods: 277 patients enrolled to undergo laparoscopic gynecologic surgery were included in the study. Women are randomized into two groups, according to the use or non-use of peritoneal lavage with saline solution at the end of laparoscopic gynecological major procedures., Results: Data show that the peritoneal lavage can significantly reduce postoperative pain in the first 36 hours after surgery, as well as patients' requests for analgesics: during the first 3 postoperative days, requests for paracetamol were lower in the YW (Yes Washing) group than the NW (No Washing) group (77 vs. 101; p<0.05); similar results are obtained considering ketorolac administration (62 vs. 71; p<0.05)., Conclusions: Peritoneal lavage after gynecological laparoscopic procedures may be effective in the reduction of postoperative pain and use of analgesics.

Background: The Scandinavian Diverticulitis (SCANDIV) trial and the LOLA arm of the LADIES trial randomized patients with Hinchey III perforated diverticulitis to laparoscopic peritoneal lavage or sigmoid resection. The aim of this analysis was to identify risk factors for treatment failure in patients with Hinchey III perforated diverticulitis., Methods: This was a post hoc analysis of the SCANDIV trial and LOLA arm. Treatment failure was defined as morbidity requiring general anaesthesia (Clavien-Dindo grade IIIb or higher) within 90 days. Age, sex, BMI, ASA fitness grade, smoking status, previous episodes of diverticulitis, previous abdominal surgery, time to surgery, and surgical competence were all tested in univariable and multivariable logistic regression analyses using an interaction variable., Results: The pooled analysis included 222 patients randomized to laparoscopic lavage and primary resection (116 and 106 patients respectively). Univariable analysis found ASA grade to be associated with advanced morbidity in both groups, and the following factors in the laparoscopic lavage group: smoking, corticosteroid use, and BMI. Significant factors for laparoscopic lavage morbidity in multivariable analysis were smoking (OR 7.05, 95 per cent c.i. 2.07 to 23.98; P = 0.002) and corticosteroid use (OR 6.02, 1.54 to 23.51; P = 0.010)., Conclusion: Active smoking status and corticosteroid use were risk factors for laparoscopic lavage treatment failure (advanced morbidity) in patients with perforated diverticulitis., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.)

Purpose: Recently, treatment of Hinchey III diverticulitis by laparoscopic peritoneal lavage has been questioned. Moreover, long-term outcomes have been scarcely reported. Primary outcome was to determine the recurrence rate of diverticulitis after a successful laparoscopic peritoneal lavage in Hinchey III diverticulitis. Secondary outcomes were identification of associated risk factors for recurrence and elective sigmoidectomy rate., Methods: A retrospective cohort study in a tertiary referral center was performed. Patients with Hinchey III diverticulitis who underwent a successful laparoscopic peritoneal lavage between June 2006 and December 2019 were eligible. Diverticulitis recurrence was analyzed according to the Kaplan-Meier and log-rank test, censoring for death, loss of follow-up, or elective sigmoid resection in the absence of recurrence. Risk factors for recurrence were identified using Cox regression analysis., Results: Sixty-nine patients had a successful laparoscopic peritoneal lavage (mean age: 63 years; 53.6% women). Four patients had an elective sigmoid resection without recurrences. Recurrence rate was 42% (n = 29) after a median follow-up of 63 months. The cumulative global recurrence at 1, 3, and 5 years was 30% (95% CI, 20-43%), 37.5% (95% CI, 27-51%), and 48.9% (95% CI, 36-64%), respectively. Smoking (HR, 2.87; 95% CI, 1.22-6.5; p = 0.016) and episodes of diverticulitis prior to laparoscopic peritoneal lavage (HR, 5.2; 95% CI, 2.11-12.81; p < 0.001) were independently associated with an increased risk of recurrence., Conclusions: Diverticulitis recurrence after a successful laparoscopic peritoneal lavage is high, decreasing after the first year of follow-up. Smoking and previous episodes of acute diverticulitis independently increase the risk of new episodes of diverticulitis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Aims: Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL., Methods: Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL., Results: 561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p < 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL., Conclusion: This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial., Methods: Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group., Results: Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan-Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy., Conclusion: Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option., (© 2022. The Author(s).)

Pneumoperitoneum is the presence of free air within the peritoneal cavity and indicates perforation of a hollow viscus. However, it may also occur in the absence of perforation and in this case, it is called spontaneous pneumoperitoneum (SP). A 57-year-old female patient who was intubated and mechanically ventilated due to respiratory failure developed abdominal compartment syndrome (ACS) secondary to massive SP. Peritoneal lavage was performed for the patient both to achieve decompression and to support the diagnosis. Many surgeons proceed with laparotomy as a reflex response for SP due to lack of awareness of the condition. However, laparotomy has no place in this setting. SP coexisting with ACS is extremely rare. With this case report, we aimed to raise awareness of SP among physicians and help avoid unnecessary laparotomies.

Background: The standard treatment for Hinchey III perforated diverticulitis with peritonitis was resection with or without a stoma, but recent trials have shown that laparoscopic lavage is a reasonable alternative. This registry-based Swedish study investigated results at a national level to assess safety in real-world scenarios., Methods: Patients in Sweden who underwent emergency surgery for perforated diverticulitis between 2016 and 2018 were studied. Inverse probability weighting by propensity score was used to adjust for confounding factors., Results: A total of 499 patients were included in this study. Laparoscopic lavage was associated with a significantly lower 90-day Comprehensive Complication Index (20.9 versus 32.0; odds ratio 0.77, 95 per cent compatibility interval (c.i.) 0.61 to 0.97) and overall duration of hospital stay (9 versus 15 days; ratio of means 0.84, 95 per cent c.i. 0.74 to 0.96) compared with resection. Patients had 82 (95 per cent c.i. 39 to 140) per cent more readmissions following lavage than resection (27.2 versus 21.0 per cent), but similar reoperation rates. More co-morbidity was noted among patients who underwent resection than those who had laparoscopic lavage., Conclusion: Laparoscopic lavage is safe in routine care beyond trial evaluations., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To evaluate rates of postoperative infection in patients with acute purulent appendicitis or gangrenous perforated appendicitis after laparoscopic appendectomy (LA). Methods: In this retrospective cohort study the medical records of patients who had undergone LA for acute appendicitis at Yijishan Hospital of Wannan Medical College between January 2015 and December 2019 were reviewed. The patients were divided into 2 groups based on the sequential order in which peritoneal irrigation, suction, and extraction of appendix had been performed. In Group 1 peritoneal irrigation and suction had been performed before extraction of the appendix, and in Group 2 they had been performed after extraction of the appendix. Demographic details, surgery duration, time to first flatus, length of hospital stay, total hospitalization expenses, and postoperative complications were analyzed. Results: The final study sample included 571 patients, 116 (20.3%) in Group 1 and 455 (79.7%) in Group 2. There were no significant differences in demographic characteristics, preoperative white blood cell counts, surgery durations, lengths of hospital stay, or total hospitalization expenses between the 2 groups ( P  > .05). Time to first flatus was significantly shorter in Group 1 (2.1 ± 0.5 days) than in Group 2 (2.3 ± 0.6) ( P  = .016), and the incidence of surgical wound infection was lower in Group 1 (6.9%) than in Group 2 (14.1%) ( P  = .038). There were no significant differences in the rates of intra-abdominal abscess, small bowel obstruction, or readmission within 30 days between the 2 groups ( P  > .05). Conclusion: Patients with acute purulent appendicitis or gangrenous perforated appendicitis are at high risk of surgical wound infection. Peritoneal irrigation and suction before appendix extraction may reduce the incidence of postoperative wound infection.

Background: Staged lavage was first introduced in the 1970s and now serves as a therapeutic option for septic patients with peritonitis. A central aspect of this treatment concept is leaving the abdomen open after a wide incision. To evaluate the influence of transverse vs. median access to the abdomen in staged lavage, data from the authors' patients were analyzed. Methods: To evaluate patients with peritonitis, prospective intensive care data were examined together with data on the surgical details. The main aspects covered here were the surgical details of the lavage (namely, transverse vs. median laparotomy), number of lavages, fascia closure, wound-healing disorders, and observed lethality, in combination with the preoperatively evaluated SAPS-II score, expected hospital lethality, patient age, and the Mannheim Peritonitis Index. Results: Between January 2008 and December 2018, 522 patients were treated with open abdomen and staged lavage. The mean age of the patients was 66.0 years (standard deviation (SD) 15.9 years). A median incision was used in 140 cases, and transverse laparotomy was performed in 382. The mean SAPS-II score was 46.5 (SD 15.7), expected lethality was 39.6% (SD 26.3%), and observed lethality was 19.9%. On average, two lavages were performed after the index operation. Transverse incision was significantly less likely to cause wound-healing disorder (p=0.03), and fascial dehiscence was observed less frequently in the transverse laparotomies group than in median incisions in the statistical trend (p=0.06). Conclusion: In summary, staged lavage reduced expected lethality in patients with peritonitis. Transverse incision caused wound-healing disorders and fascial dehiscence less often. Therefore, the indication for transverse laparotomy should be generous, as this form of treatment is advantageous in case of peritonitis., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2020 Petersen et al.)

Competing Interests: Nil.

Purpose: Laparoscopic peritoneal lavage (LPL) is feasible in selected patients with pelvic abscess and generalized purulent peritonitis caused by acute diverticulitis. We aimed to compare LPL and laparoscopic sigmoidectomy (LS) in complicated acute diverticulitis., Methods: This prospective, observational, multicenter study included patients with a pelvic abscess not amenable to conservative management and patients with Hinchey III acute diverticulitis, from 2015 to 2018. Sixty-six patients were enrolled: 28 (42%) underwent LPL and 38 (58%) underwent LS. In LS, patients had a primary anastomosis, with or without ileostomy, or an end colostomy (HA). Major outcomes were mortality, morbidity, failure of source control, reoperation, length of stay, and diverticulitis recurrence., Results: Patient demographics were similar in the two groups. In LPL, ASA score > 2 and Mannheim Peritonitis Index were significantly higher (p = 0.05 and 0.004). In LS, 24 patients (63%) had a PA and 14 (37%) an HA. No death was recorded. Overall, morbidity was 33% in LPL and 18% in LS (p = 0.169). However, failure to achieve source control of the peritoneal infection and the need to return to the operating room were more frequent in LPL (p = 0.002 and p = 0.006). Mean postoperative length of stay was comparable (p = 0.08). Diverticular recurrence was significantly higher in LPL (p = 0.003)., Conclusion: LPL is related to a higher reoperation rate, more frequent postoperative ongoing sepsis, and higher recurrence rates. Therefore, laparoscopic lavage for perforated diverticulitis carries a high risk of failure in daily practice.

Background: Diverticulitis is one of the most common gastrointestinal diseases in western population. Colonic resection is recommended by international guidelines as a routinely used technique for purulent diverticulitis. Laparoscopic lavage was introduced as a non-resection alternative. The studies available so far have shown contradictory results. This meta-analysis aims to compare laparoscopic lavage versus colonic resection in patients with Hinchey Ⅲ-Ⅳ diverticulitis., Methods: We did a systematic review of articles published before March 20, 2019, with no language restriction by searching PubMed, Cochrane library, EMBASE databases, clinicaltrials.gov, and Google Scholar databases. We included all RCTs and cohort studies comparing outcomes between patients with Hinchey Ⅲ-Ⅳ diverticulitis undergoing laparoscopic lavage versus colonic resection. Important outcomes were mortality, complications, length of stay, readmission and reoperation rates. We combined data to assess the outcomes using DerSimonian and Laird random-effects model., Results: A total of 569 patients with diverticulitis of which more than 80% were Hinchey Ⅲ were enrolled from 3 RCTs and 5 cohort studies. Laparoscopic lavage was associated with shorter operative time (WMD -78.9, 95%CI -100.58 to -57.11, P < 0.0001) and total postoperative hospital stay (WMD -7.62, 95%CI -11.60 to -3.63, P = 0.0002) but a higher rate of intra-abdominal abscess (OR 2.69, 95%CI 1.39 to 5.21, P = 0.0032) and secondary peritonitis (OR 5.30, 95%CI 1.91 to 14.73, P = 0.0014)., Conclusion: Laparoscopic lavage for patients with Hinchey Ⅲ to Ⅳ diverticulitis does provide similar mortality, shorter operative time and hospital stay. However, the evidence so far suggests that it might be inadequate for sepsis control and may result in more unplanned reoperations. Further studies are needed to standardize the formal indication for laparoscopic lavage., (Copyright © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to determine whether copious irrigation of peritoneal cavity during laparoscopic appendectomy for complicated appendicitis effectively reduces the incidence of postoperative complications and improves the postoperative recovery in adults compared with suction alone., Methods: In this prospective randomized trial, adult patients with complicated appendicitis were randomized to "irrigation and suction"(IS) group or "suction only"(SO) group. All surgery was performed with a standardized 3-port laparoscopic approach. The IS group received peritoneal irrigation with a minimum of 2000 mL sterile normal saline. The study primary outcomes included wound infection and postoperative intra-abdominal abscess. The study secondary outcomes included duration of operation, first anal exsufflation time, duration of hospital stay and hospital charges. Chi-squared and t-tests were used to analyze the study data., Results: Between January 2015 and June 2016, a total of 260 patients with complicated appendicitis were enrolled in the study. The peritoneal irrigation resulted in a longer operation time (51.6 ± 16.1 vs. 41.5 ± 15.2 min, p <0.001). There was no significant difference in the rate of wound infection between the two groups. However, the patients who received irrigation had a lower postoperative intra-abdominal abscess rate (3.1% vs. 9.2%, p = 0.039), earlier anal exsufflation (25.2 ± 16.5 vs. 30.7 ± 18.1 hr, p = 0.011), shorter hospital stay (10.2 ± 2.5 vs. 12.5 ± 2.8 days, p <0.001) and lower hospital charges (¥14,592 ± 2,251 vs. 16,674 ± 2,163, p <0.001) compared to those received suction alone., Conclusions: The study findings revealed that copious irrigation of peritoneal cavity during laparoscopic appendectomy could decrease the incidence of postoperative intra-abdominal abscess in adult patients with complicated appendicitis. These patients also had faster postoperative recovery and lower hospital charges.

Background: Although peritoneal lavage with povidone-iodine (PVPI) is frequently performed after surgery on the gastrointestinal tract, the effects of PVPI on the intestinal epithelial barrier are unknown. The purpose of this study was to investigate the effects of abdominal irrigation with PVPI on the intestinal epithelial barrier in a colorectal cancer (CRC)-induced rat model., Materials and Methods: The CRC model was induced in rats with azoxymethane and dextran sodium sulfate. Next, a total of 24 male CRC-induced rats were randomly divided into three groups (n = 8): (1) a sham-operated group, (2) an NS group (peritoneal lavage 0.9% NaCl), and (3) a PVPI group (peritoneal lavage with 0.45%-0.55% PVPI). The mean arterial pressure was continuously monitored throughout the experiment. The levels of plasma endotoxin and D-lactate, blood gases, and protein concentration were measured. The ultrastructural changes of the epithelial tight junctions were observed by transmission electron microscopy., Results: The mean arterial pressure after peritoneal lavage was lower in the PVPI group than that in the NS group. The protein concentration and levels of endotoxin and D-lactate were higher in the PVPI group than they were in the PVPI group. In addition, PVPI treatment resulted in a markedly severe metabolic acidosis and intestinal mucosal injury compared with NS rats., Conclusions: Peritoneal lavage with PVPI dramatically compromises the integrity of the intestinal mucosa barrier and causes endotoxin shock in CRC rats. It is unsafe for clinical applications to include peritoneal lavage with PVPI in colorectal operations., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Recent randomized trials demonstrated that laparoscopic lavage compared with resection for Hinchey III perforated diverticulitis was associated with similar mortality, less stoma formation but a higher rate of early reintervention. The aim of this study was to compare 1-year outcomes in patients who participated in the randomized Scandinavian Diverticulitis (SCANDIV) trial., Methods: Between February 2010 and June 2014, patients from 21 hospitals in Norway and Sweden presenting with suspected perforated diverticulitis were enrolled in a multicentre RCT comparing laparoscopic lavage and sigmoid resection. All patients with perforated diverticulitis confirmed during surgery were included in a modified intention-to-treat analysis of 1-year results., Results: Of 199 enrolled patients, 101 were assigned randomly to laparoscopic lavage and 98 to colonic resection. Perforated diverticulitis was confirmed at the time of surgery in 89 and 83 patients respectively. Within 1 year after surgery, neither severe complications (34 versus 27 per cent; P = 0·323) nor disease-related mortality (12 versus 11 per cent) differed significantly between the lavage and surgery groups. Among the 144 patients with purulent peritonitis, the rate of severe complications (27 per cent (20 of 74) versus 21 per cent (15 of 70) respectively; P = 0·445) and disease-related mortality (8 versus 9 per cent) were similar. Laparoscopic lavage was associated with more deep surgical-site infections (32 versus 13 per cent; P = 0·006) but fewer superficial surgical-site infections (1 versus 17 per cent; P = 0·001). More patients in the lavage group underwent unplanned reoperations (27 versus 10 per cent; P = 0·010). Including stoma reversals, a similar proportion of patients required a secondary operation (28 versus 29 per cent). The stoma rate at 1 year was lower in the lavage group (14 versus 42 per cent in the resection group; P < 0·001); however, the Cleveland Global Quality of Life score did not differ between groups., Conclusion: The advantages of laparoscopic lavage should be weighed against the risk of secondary intervention (if sepsis is unresolved). Assessment to exclude malignancy (although uncommon) is advised. Registration number: NCT01047462 ( http://www.clinicaltrials.gov)., (© 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Laparoscopic peritoneal lavage is an alternative to sigmoid resection in Hinchey III diverticulitis (generalized purulent peritonitis). The main limitation of laparoscopic peritoneal lavage is the higher rate of reoperation for persistent sepsis in comparison with sigmoid resection., Objective: The purpose of the current study was to identify risk factors for laparoscopic peritoneal lavage failure in patients who have Hinchey III diverticulitis., Design: This was a retrospective multicenter study., Settings: The study was conducted in 3 clinical sites in France., Patients: From 2006 to 2015, all consecutive patients undergoing emergent surgery for diverticulitis were reviewed. All patients operated on with laparoscopic peritoneal lavage for laparoscopically confirmed Hinchey III diverticulitis were included., Main Outcome Measures: The main outcome was laparoscopic peritoneal lavage failure, defined as reoperation or death at 30 postoperative days., Results: A series of 71 patients (43 men, mean age 58 ± 15 years) were operated on with laparoscopic peritoneal lavage for Hinchey III diverticulitis. Laparoscopic peritoneal lavage failed in 14 (20%) of them: 1 died and 13 underwent reoperations. No major complication (Dindo-Clavien score ≥3) occurred after reoperation. Immunosuppressive drugs (p = 0.01) and ASA grade ≥3 (p = 0.02) were associated with laparoscopic peritoneal lavage failure after univariate analysis. Multivariate analysis identified only immunosuppressive drug intake (steroids or chemotherapy for cancer) as an independent predictive factor. Mean length of stay was 14.9 days (5-67). At the end of the 30 first postoperative days, 12 (17%) patients had a stoma., Limitations: The study was limited by its retrospective nature and the small size of the cohort., Conclusion: Our results highlight immunosuppressive drug intake as a major risk factor for laparoscopic peritoneal lavage failure in patients who have Hinchey III diverticulitis. Immunosuppression and severe comorbidities (ASA ≥3) should be considered when selecting a surgical option in patients with Hinchey III diverticulitis. See Video Abstract at http://links.lww.com/DCR/A423.

Necrotising enterocolitis (NEC) is a neonatal surgical emergency. At its early stages, the management of NEC is largely medical using broad-spectrum antibiotics, gut rest and total parental nutrition. The only absolute indication for surgery is an intra-abdominal perforation. There are several relative indications for surgery based on clinical, biochemical and radiological parameters. Once the decision to intervene is made, several approaches may be taken. Peritoneal lavage can be used as a salvage procedure or definitive management in some cases. The most common approach taken is bowel resection with enterostomy formation. There is a role for primary anastomosis of bowel in limited NEC. In severe, multi-focal NEC a high diverting jejunostomy or "clip and drop technique" can be used. Laparoscopy has a limited role and is not widespread. The surgical complications of NEC include stoma related morbidity, anastomotic leak/stricture and short-bowel syndrome. Long-term data on neurodevelopmental outcomes is sparse but the present literature is suggestive of a negative impact in cases of surgically managed NEC., (Crown Copyright © 2016. Published by Elsevier Ireland Ltd. All rights reserved.)

Aim: to improve the results of advanced peritonitis management., Material and Methods: 743 patients with advanced peritonitis were studied. Patients were divided into 2 groups depending on treatment strategy., Results: Programmed relaparotomy combined with removable draining musculoaponeurotic seams during laparotomy closure decreased mortality from 47.8±2.7% to 24.1±2.3% (p<0.001) and provided 4-fold reduction of postoperative suppuration incidence (p<0.001). Refusal from removable draining musculoaponeurotic seams and use of only cutaneous seams in persistent abdominal hypertension were associated with further decrease of mortality to 15.8±2.7% (p<0.05)., Conclusion: Programmed relaparotomy combined with removable draining musculoaponeurotic seams are advisable for advanced peritonitis management. Laparotomy closure with only cutaneous seams is indicated in case of persistent abdominal hypertension. Large eventration always requires abdominal wall repair. APACHE-III scale scores have significant prognostic value in patients with advanced peritonitis.

Objective: To evaluate the feasibility, surgical outcomes and complications of laparoscopic restaging surgery for women with unexpected ovarian malignancy., Study Design: We conducted a retrospective chart review of 14 women with unexpected ovarian malignancy who underwent laparoscopic restaging surgery including peritoneal washing cytology, laparoscopic pelvic and paraaortic lymphadenectomy up to the left renal vein level, omentectomy, and multiple peritoneal biopsies, and hysterectomy except three fertility saving surgery., Results: The median age and median body mass index women were 49 years (range, 22-63) and 24.2m/kg(2) (range, 18.9-25.3), respectively. The median operating time was 230min (range, 155-370). The median numbers of harvested pelvic and paraaortic lymph nodes were 26 (range, 6-41) and 18 (range, 2-40), respectively. The median return of bowel activity was 28h (range, 21-79). Four of the women were upstaged from the initial presumed stage. There were two intraoperative complications, laceration of the inferior vena cava and cisterna chyli rupture. There was one postoperative complication, port-site metastasis. There was no conversion to laparotomic surgery. The median follow-up period was 33 months. Thirteen of the patients have no evidence of recurrences, however one patient died after 22 months after the surgery., Conclusion: Laparoscopic restaging surgery, performed by a specialized laparoscopic oncologist with sufficient laparoscopic experience and a well-trained operating team, is both feasible and effective in the management of unexpected ovarian malignancies., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Systemic hypothermia may reduce infarct size if established before reperfusion. The large surface area of the bowel may facilitate rapid hypothermia. We therefore examined the feasibility, safety, and efficacy of hypothermia induced by an automated peritoneal lavage system in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention., Methods and Results: Patients with ST-segment-elevation myocardial infarction within 6 hours of symptom onset were randomized to peritoneal hypothermia before and for 3 hours after percutaneous coronary intervention versus control. The primary safety end point was the 30-day composite rate of death, reinfarction, ischemia-driven target vessel revascularization, major bleeding, sepsis, pneumonia, peritonitis, severe arrhythmia, or renal failure. The primary efficacy end point was infarct size assessed by cardiac MRI on day 3 to 5. Fifty-four patients were randomized at 7 centers to hypothermia (n=28) versus control (n=26). Hypothermia was successfully initiated in 96.3% of patients, and median [interquartile range] temperature at first balloon inflation was 34.7 [34.0-34.9]°C. Median door-to-balloon times in the hypothermia and control groups were 62 [51-81] and 47 [37-55] minutes, respectively (P=0.007). The primary safety end point occurred in 6 (21.4%) and 0 (0%) patients in the hypothermia and control groups, respectively (P=0.01), including 3 versus 0 stent thrombosis events. Infarct size was 17.2% [15.1-20.6] and 16.1% [10.0-22.2] in the hypothermia and control groups, respectively (P=0.54)., Conclusions: Peritoneal hypothermia is feasible and achieves rapid cooling with only a modest increase in treatment times in the setting of ST-segment-elevation myocardial infarction. However, in the present randomized trial, peritoneal hypothermia was associated with an increased rate of adverse events without reducing infarct size., Clinical Trial Registration Url: http://www.clinicaltrials.gov. Unique identifier: NCT01655433., (© 2015 American Heart Association, Inc.)

Background: Over the past few years, the laparoscopic peritoneal lavage has emerged as a therapeutic alternative to standard resection procedures. However, its effectiveness and applicability remain debatable., Objective: The aim of this study was to assess laparoscopic lavage in controlling abdominal sepsis secondary to purulent peritonitis., Design: This study was conducted as a retrospective analysis of prospectively collected data., Setting: This study was conducted at a single tertiary care institution., Patients: Patients requiring emergency surgery for perforated diverticulitis and generalized peritonitis between June 2006 and June 2013 were identified from a prospective database. Laparoscopic assessment was considered in all of the hemodynamically stable patients, and laparoscopic lavage was performed according to intraoperative strict criteria., Main Outcome Measures: Primary outcomes were the effectiveness and applicability of laparoscopic lavage. Secondarily, feasibility, morbidity, and mortality were also assessed., Results: Seventy-five patients required emergency surgery for generalized peritonitis secondary to perforated diverticulitis. Forty-six patients who underwent laparoscopy presented a purulent generalized (Hinchey III) peritonitis and were examined under the intention-to-treat basis to perform a laparoscopic lavage. Thirty-two patients (70.0%; 95% CI 56.2-82.7) had no previous episodes of diverticulitis. Thirty-six patients (78.0%; 95% CI 66.3-90.1) had free air on a CT scan. The conversion rate was 4% (95% CI 0-10). The feasibility of the method was 96.0% (95% CI 90.4-100), and its applicability was 59.0% (95% CI 44.8-73.2). Median operative time was 89 minutes (range, 40-200 minutes). Postoperative morbidity was 24.0% (95% CI 11.7-36.3), and the mortality rate was 0%. We registered 5 failures, and all of them underwent reoperation. The effectiveness of the procedure was 85% (95% CI 76-93)., Limitations: This was a single-institution retrospective study., Conclusions: The effectiveness of laparoscopic lavage seems to be high. Although its applicability is lower, it could be applied in more than half of patients requiring emergency surgery. This alternative strategy should be considered when laparoscopic assessment reveals Hinchey III diverticulitis.

Normothermic intraperitoneal perfusion (IPEP) and hyperthermic intraperitoneal perfusion (HIPEP) were performed in 44 Wistar female rats with transplanted ascites tumor of the ovary. Opportunities of intraoperative hyperthermic perfusion application in treatment of peritoneal carcinomatosis. Antineoplastic affects were evaluated according to increase of animals' survival. IPEP and HIPEP increase median survival time by 78% (p=0.307) and 150% (p=0.005) respectively in comparison with conventional intraperitoneal introduction of physiological solution. Thus HIPEP has statistically more significant antineoplastic affect in vase of peritoneal carcinomatosis.

An analysis of complex examination and results of treatment was made in 290 patients with diffuse peritonitis. The patients were divided into two groups according to way of sanation of the abdominal cavity. The sanation with 0.03% aqueous solution of sodium hypochlorite was used for the first group of 155 patients. The immobilized forms of sodium hypochlorite in carboxymethyl cellulose gel were applied in the second group. The rate of postoperative complications was decreased on 15.4%, the lethality--on 8.2% in the case of application of the immobilized forms of sodium hypochlorite. The developed technology allowed increasing of physical component of life quality of the patients in 1.3 times, though it didn't influence on psychical component.

Pseudomyxoma peritonei causes marked accumulation of jelly-like ascites in the peritoneal cavity. Removal of much mucinous ascites by irrigating the cavity appears to be an effective treatment. We describe a patient who underwent the irrigation with sodium bicarbonate solution and developed critical alkalemia. A 68-year-old woman with normal renal function was operated on for recurrent pseudomyxoma peritonei. Fol- lowing the excision of primary lesion, her intraperitoneal cavity was irrigated with 10 1 of 7% sodium bicarbonate in about 45 minutes. Thirty minutes after irrigation, blood gas analysis revealed severe metabolic alkalosis (pH 7.714, BE 25.6 mmol x l-1 ) with electrolyte disorder (Na 157.8 mmol x l-1 K 2.31mmol x l-1, Ca 0.73 mmol x l-1). Hypotension (<60 mmHg) and sinus tachycardia (>130 beats x min -1) supervened 75 minutes later. Transferring to the ICU, she was given KC1 solution intravenously based on serial blood analysis while on mechanical ventilation. The next day acid-base disturbance returned spontaneously to normal (pH 7.45, BE 8.0mmol x l-1), leading to endotracheal extubation. Electrolyte imbalance was gradually resolved on 2nd POD and she was discharged from the ICU. Intraperitoneal irrigation with sodium bicarbonate requires special perioperative considerations for lifethreatening alkalemia, especially in a patient with renal impairment.

Injuries and illness associated with major trauma that require lifesaving procedures, such as surgical airway, chest tube thoracotomy, emergency department thoracotomy, early recognition and treatment of compartment syndrome, and venous cutdown, are seen in the emergency department. The emergency medicine physician must be proficient in recognizing these injuries and their associated complications and be able to provide appropriate management. This article discusses the most common trauma-related procedures in which emergency physicians must be proficient. A description of each procedure is discussed as well as the indications, contraindications, equipment, technique, and potential complications., (Copyright © 2013 Elsevier Inc. All rights reserved.)

A 74-year-old woman was admitted to our hospital with weight loss and sense of abdominal distension. She was diagnosed to have pseudomyxoma peritonei based on careful examinations in the surgical department of our hospital. She therefore underwent elective surgery consisting of an ileocecal resection under general anesthesia. The induction of anesthesia was very smooth, but the patient's blood pressure became unstable during the operation. As a result, we inserted an arterial catheter into the radial artery, and the blood gas analysis showed severe hyperglycemia and hyponatremia. We determined that a massive amount of intraperitoneal lavage fluid with 5% glucose had been absorbed into the blood vessels. We administered regular insulin to manage the hyperglycemia and also mannitol and furosemide to treat the hyponatremia that had been caused by water intoxication. Thereafter, both the hyperglycemia and hyponatremia improved quickly, and the patient was extubated safely. We had little prior knowledge about pseudomyxoma peritonei, and therefore had not expected such an occurrence. Moreover we did not sufficiently provide the surgical team with all of the patient's information. In the future, we will maintain close cooperation with the surgical team and establish an appropriate anesthesia plan when we encounter patients presenting with pseudomyxoma peritonei.

Purpose: The objective of this study was to assess the cytokine serum levels of IL-6 and TNF-α in rats subjected to fecal peritonitis and treated with peritoneal lavage with 0.2% ropivacaine by peritoneal lavage., Methods: We subjected 16 Wistar rats to laparotomy 6 hours after the induction of fecal peritonitis with autogenous stool and subsequently divided the rats randomly into 4 groups: I-control, no treatment; II- drying of the abdominal cavity; III- lavage of the abdominal cavity with 3 mL of 0.9% normal saline and drying; IV- lavage of the abdominal cavity with 3 mL of 0.2% ropivacaine and drying. Six hours following the laparotomy, the animals underwent cardiac puncture, and 1 mL of blood was collected for cytokine assessment before the animals were euthanized., Results: The lavage with ropivacaine resulted in smaller TNF-α levels compared with those observed in the other treatment groups (p <0.05). Regarding IL-6, the ropivacaine group showed lower cytokine levels than those observed in groups I and II, but there was no significant difference (p> 0.05) between groups III and IV., Conclusion: Peritoneal lavage with 0.2% ropivacaine was shown to reduce plasma levels of IL-6 and TNF-α in the treatment of fecal peritonitis in rats.

Objective: To determine whether avoiding intra-abdominal irrigation at cesarean delivery will decrease rates of intraoperative and postoperative gastrointestinal disturbance without increasing postoperative morbidity., Methods: This was a randomized controlled trial of patients undergoing cesarean delivery. Patients were randomized to irrigation after closure of the hysterotomy compared with no irrigation. The cesarean delivery was otherwise performed in the usual fashion. The patient was blinded to treatment once assigned. The primary outcome was maternal intraoperative nausea. The secondary outcomes were postoperative maternal gastrointestinal disturbance and incidence of maternal infectious morbidity., Results: Two hundred thirty-six patients were randomized; 126 were randomized to no irrigation and 110 were randomized to irrigation. Both were similar with respect to age, body mass index, operative time, blood loss, uterine incision, tubal ligation, exteriorization of the uterus, packing of bowel, lysis of adhesions and bladder flap, and peritoneal or rectus muscle closure. Intraoperative nausea was significantly more frequent with irrigation compared with no irrigation (51 of 110 [46.4%] compared with 36 of 126 [28.26%]; relative risk 1.62, 95% confidence interval 1.15-2.28). We noted no statistically significant differences for intraoperative emesis, preoperative chorioamnionitis, postoperative nausea, postoperative emesis, postoperative antiemetic administration, endometritis, or postoperative febrile morbidity. There was an increased trend of postoperative nausea and antiemetic use with irrigation., Conclusion: Irrigation at cesarean delivery increases intraoperative nausea without decreasing postoperative infectious morbidity., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01479712., Level of Evidence: I.

The 1st group consisted of 68 patients with the diffuse peritonitis, who were treated with the use of traditional approach, i.e., laparotomy, elimination of the peritonitis source, nasointestinal intubation, abdominal cavity sanation and drainage. Within 24--48 hours all these patients had videoendoscopic abdominal sanation with the injection of 200 ml 0.03% water solution of sodium hypochlorite. The 2nd group, consisted of 41 patients. The first treatment stage was the same, but during the videoendoscopic stage the pulsing stream of the antiseptic was used and the procedure ended with intraabdominal injection of 200 ml 0.03% water solution of sodium hypochlorite immobilized in gel. All patients of the 2nd group showed better recovery results.

Background: Hyperthermic Intraoperative Peritoneal Lavage (HIPL) is useful for bacterial decontamination and prevention of hypothermia during damage-control surgery (DCS). Little is known about the effect of HIPL on intra-abdominal pressure (IAP) alone or in combination with peritonitis., Aim: To determine the effects of HIPL at graded temperatures on IAP in the context of DCS., Materials and Methods: A total of 40 rabbits randomly assigned to aseptic-thermal (AT) and peritonitis-thermal (PT) groups and subgroups underwent HIPL at 40°C, 43°C, 46°C, and 49°C. The AT subgroup assigned 40°C was the control group. HIPL was done with a volume of 100 ml/kg. Hourly IAP measurement by two independent observers who were mutually blinded was done through a peritoneal balloon pouch connected to a manometer for 12 hours., Results: All rabbits in group AT survived for at least 11 hours, while all the rabbits in group PT died between 4 and 8 hours. There was significant IAP rise at 4 hours in all subgroups in comparison with the control (I AT40):III AT46 (P < 0.01), IV AT49 (P < 0.001), V PT40 (P < 0.01), VI PT43 (P < 0.01), VII PT46 (P < 0.001), and P 49 (P < 0.001) except II AT43 ( P = 0.85). Multiple linear regression analysis showed a positive correlation:Coefficient of regression {r = 0.85 (AT) and r = 0.89 (PT)} and coefficient of determination {r2 = 0.73 (AT) and r2 = 0.80 (PT)}., Conclusion: Our findings suggest that beyond 3°C above the normal body temperature in this species, HIPL acts synergistically with peritonitis to exacerbate intra-abdominal hypertension and is associated with a shortened survival postoperatively due to abdominal compartment syndrome.

We report a case of fatal sodium poisoning due to the unintentional use of 20% hypertonic saline serum during peritoneal lavage after intestinal resection. The patient presented with unconsciousness, metabolic acidosis, and plasma sodium concentration of 193 mE/l. After 3 hours, he developed paroxysmal supraventricular tachycardia, hyperthermia, generalized tonic-clonic convulsions, disseminated intravascular coagulation, and adult respiratory distress syndrome. The patient died 15 hours after the operation. Pathological examination revealed cerebral and lung oedema, pericentral hepatic necrosis, and fibrin thrombi in the lungs, stomach, and kidneys. We review, in addition, other reported cases of sodium poisoning.

Diagnostic peritoneal lavage (DPL) is a highly accurate test for evaluating intraperitoneal hemorrhage or a ruptured hollow viscus, but is performed less frequently today due to the increased use of focused abdominal sonography for trauma (FAST) and helical computed tomography (CT). All three of these exams have advantages and disadvantages and thus each still play unique roles in the evaluation of abdominal trauma. Since DPL is performed less frequently today, a review of its indications, technique, and interpretation is pertinent.

Purpose: To study the effects of peritoneal lavage with a 2% lidocaine solution, on the survival of the rats submitted to peritonitis caused by their own feces., Methods: Forty-eight Wistar rats, weighting between 300 g and 330 g (mean, 311,45 +/-9,67 g), were submitted to laparotomy 6 hours following induction of fecal peritonitis. Animals were randomly divided into four groups of 12 each as follows: 1- Control, no therapy; 2- Drying of the abdominal cavity; 3- Peritoneal lavage with saline and drying; 4- Peritoneal lavage with a 2% lidocaine solution and drying. Animals that died were submitted to necropsy and the time of their death recorded; survivors were killed on the post-operation 11th day and necropsied., Results: Death occurred within 52 h in all animals of group 1; within 126 h in 100% of those of group 2; within 50 h in 50% of those of group 3. All animals of group 4 survived. Survival on the 11 th day was higher in groups 3 and 4 than in groups 1 and 2 (p<0.001), and higher in group 4 than in group 3 (p<0.01)., Conclusion: Peritoneal lavage with a 2% lidocaine saline solution without adrenaline, prevented the mortality of all animals with fecal peritonitis.

Purpose: To evaluate histopathologic alterations of the peritoneum exposed to heat shock., Methods: Sixty rats were randomly distributed into 6 groups: Heat Shock (HS), High Temperature (HT), Body Temperature (BT), Temperature 0oC (TZ), Sham (SH) and Control (CG) with 10 animals each. The peritoneal cavity of animals from groups HS, HT, BT and TZ was irrigated with NaCl solution 0.9% at temperatures 50 degrees C, 0 degrees C, 50 degrees C, 37 degrees C and 0 degrees C, respectively. For animals from group SH, the procedures were simulated and those from group CG, laparotomy and biopsies were conducted. Twenty-four hours later, biopsies of the peritoneum for exams under light and electronic microscopy were performed., Results: Edema was found in groups HS 80%, HT 60%, BT 30% TZ 70%, SH 40% and CG 30%. Vascular congestion was found in groups HS 20%, HT 30%, BT 10% and TZ 20%. Erythrocyte extravasation was found in groups HT 60% and SH 10%. Mesothelium destruction was found in 100% of specimens from groups HS, HT, BT, TZ, SH and CG 90%. Necrosis was found in groups HS 30%, HT 20% and BT 10%. The mean peritoneal thickness ranged from 42.26 microm (TZ) to 26.42 microm (CG)., Conclusion: The heat shock caused no deaths, but promoted significant peritoneal edema without affecting the other histopathologic indicatives.

Pseudomyxoma peritonei is a condition characterized by the production of a large amount of mucopolysaccharide by a neoplastic epithelium. Although surgical removal of the mucinous ascites may be attempted, complete removal of the material is difficult. Thus, intra-peritoneal lavage with the liquid containing glucose or dextrose has been advocated to prevent reaccumulation of the mucus and complications such as bowel obstruction requiring repeated surgery. We report a case showing transient hyperglycemia following intra-peritoneal irrigation with 5% glucose in a patient with psudomyxoma peritonei. The patient was a 72-year-old woman. Preoperatively, she had hypertension and angina pectoris; but no history of glucose intolerance. Serum glucose was 92 mg x dl(-1). General anesthesia was induced with propofol (100 mg), vecuronium (6 mg), and fentanyl, and maintained with oxygen (33%), nitrous oxide and sevoflurane (1-2%). A mucinous tumor was found with a great deal of mucinous ascites. To remove the mucus and prevent subsequent re-accumulation, intra-peritoneal irrigation with 5% glucose in water was performed. Shortly after this procedure, the patient was found to be hyperglycemic (serum glucose 266 mg x dl(-1)) with normal oxygenation and hemodynamic data. The patient recovered uneventfully and could be extubated soon after surgery. Serum glucose level returned to 154 mg x dl(-1) one hour after surgery. Therefore, we think that this acute hyperglycemic condition, presumable due to intra-peritoneal irrigation, was transient. It is important to be aware of this dangerous complication associated with intra-peritoneal glucose instillation. Glucose monitoring during and after irrigation with glucose or dextrose is recommended.

Introduction: A meta-analysis of the literature suggests there is an increased rate of intra-abdominal abscess after laparoscopic appendectomy (LA) compared with open appendectomy (OA)., Methods: To analyze the infectious complications of LA at one tertiary care centre, we completed a retrospective chart review for all patients undergoing LA for acute appendicitis from 1995 to 2002., Results: We used established exclusion criteria to identify 175 patients with a mean age of 37.6 (standard deviation [SD] 14.5) years (95 male, 80 female). The mean operating time was 61.9 (SD 22.5) minutes. Excluding conversions to OA (14/175, 8%), operating time was 59.9 (SD 20.5) minutes. On surgical assessment, 143 patients had acute nonperforated appendicitis (17 perforated, 15 gangrenous). However, on histopathology assessment, 13 cases of normal appendix were identified (13/175, 7.4%). The overall median length of stay was 2.0 days. Three patients had significant postoperative infectious complications, including 1 wound infection and 2 cases of intra-abdominal abscesses. All abscesses were managed successfully with percutaneous drainage. An analysis of perioperative factors that might have contributed to the infectious complications revealed that each case of postoperative intra-abdominal abscess occurred in patients with gangrenous appendicitis and when extensive irrigation was used during LA., Conclusions: An institutional review demonstrates outcomes comparable with the Cochrane systematic review of the published literature. Technical issues that may impact on intra-abdominal abscess formation after LA include aggressive manipulation of the infected appendix and increased use of irrigation fluid, possibly producing greater contamination of the peritoneal cavity.

Background: Peritonitis is the established term for infective inflammation of the peritoneum, whereas serositis generally refers to aseptic inflammation of a serous cavity, including the peritoneum. Serositis may be metabolic, viral, autoimmune, drug induced, genetic, allergic or granulomatous, or due to chemical antiseptics., Cases: In our gynecological department, 4 patients had peritonitis and ascites after laparotomy., Conclusion: Based on the investigation, we think that the solution used for peritoneal lavage (0.1% octenidine dihydrochloride and 2% phenoxyethanol) played a role in the tissue toxicity that caused chemical serositis with effusion.

Peritoneal lavage was developed as a simple method to evacuate the ascitic fluid associated with pancreatitis. Although a number of studies demonstrated its efficacy in improvement of clinical manifestations, a meta-analysis of randomized control studies could not reveal its effectiveness on mortality or morbidity in severe acute pancreatitis. However, it has been well established that the ascitic fluid with pancreatitis is extremely toxic and to induce organ damage due to apoptotic cell death. Particularly, we have recently found that the ascitic fluid with pancreatitis can induce bacterial translocation due to the increase of gut permeability. Therapeutic strategy of peritoneal lavage, i.e. evacuation of toxic substances from peritoneal cavity, should be reevaluated to achieve further improvement of treatment result of severe acute pancreatitis.

This prospective clinical study was performed to determine acid-base regulating variables during abdominal lavage treatment for patients with severe peritonitis or after abdominal surgery. Arterial blood was sampled from twelve patients with secondary peritonitis and nine patients after abdominal surgery without peritonitis at three time points: immediately before, immediately after and 15 minutes after abdominal lavage with normal saline solution. The total amount of irrigant fluid, the strong ion difference [(Na+ + K+)-(Cl- + lactate-)], and total protein concentrations were determined and standard bicarbonate, standard base excess were calculated from pH and PaCO2. Peritonitis patients developed a moderate alkalaemia (pH 7.440-7.485). The alkalaemia was unmasked after optimization of mild hypoventilation, but was supported by a decrease in protein concentration of about 3.4 mEql/l in the first 15 minutes after the lavage. There was no marked increase in chloride concentration in either the peritonitis or the control group. The data indirectly exclude major fluid absorption during abdominal lavage with 3000 to 6000 ml normal saline, given that we found no clinically relevant electrolyte and acid-base changes that might be expected after rapid fluid absorption. The factors of major influence in acid-base regulation were ventilation and protein loss in the course of abdominal lavage. Monitoring of the Stewart variables is an easily applicable method of monitoring acid-base regulating variables in the perioperative course of patients undergoing abdominal lavage therapy.

Background and Aims: Chlorhexidine is known as a substance that produces adhesions. However, in an experimental model of peritoneal injury, lavage with chlorhexidine and saline solutions produced a similar number of adhesions. This study was designed to test the hypothesis that chlorhexidine gluconate 0.05% solution used for the treatment of peritonitis increases formation of postoperative peritoneal adhesions as compared to standard lavage with saline solution., Material and Methods: Forty Wistar rats were randomly allocated to gastric or faecal peritonitis groups. In each group rats were further randomly subdivided into saline or chlorhexidine peritoneal lavage groups. After 30 days the rats were killed and intraperitoneal adhesions were evaluated by adhesion score and grading., Results: Adhesion scores were statistically significantly different between saline and chlorhexidine groups in both gastric and faecal peritonitis models. In the faecal peritonitis chlorhexidine group a 20% small bowel intussusception rate was observed, while there were no such complications in the other study groups. The conglomerate of organs formed by dense adhesions was present in 60% of cases when gastric peritonitis was lavaged by chlorhexidine and in only 10% when saline solution was used ( P<0.05). Neither chlorhexidine nor saline solutions have caused such dense adhesions in faecal peritonitis., Conclusion: Peritoneal lavage with chlorhexidine gluconate 0.05% solution in the treatment of experimental peritonitis results in increased adhesion formation.

Background: Abdominal lavage is a common surgical practice, but few studies have been conducted to assess its efficacy at removing cells from the abdominal cavity, particularly during laparoscopic surgery., Methods: After three 12-mm trocars were inserted into six female 30-kg pigs at the umbilicus left and right iliac fossae, the abdomen was insufflated with carbon dioxide. The pelvis of each pigs was injected with 6 million radiolabeled LIM 1215 cells. Then the abdominal cavity was irrigated with either 500 ml 0.9% saline, 500 ml 10% betadine solution, or 1 L 0.9% saline. A maximum of 5 L of solution was used for each animal. The lavage fluid was suctioned into separate containers after each aliquot, and each container was measured for radioactivity., Results: Significantly greater numbers of cells were removed by lavage by the first to third lavage cycle; however, after four lavage cycles, relatively few cells were removed by each further cycle. No difference was observed between 500-ml and 1-L aliquots. Additionally, the mechanical efficacy of 0.9% saline and 10% betadine solution appeared similar., Conclusion: These findings suggest that optimal lavage consists of four irrigation/suction cycles utilizing 500-ml aliquots.

Laparoscopy to treat abdominal infections is becoming more and more popular. The effects of the CO(2) pneumoperitoneum have not yet been completely clarified. In a rat peritonitis model, therefore, we investigated the influence of laparoscopic lavage in comparison with the conventional technique. A defined multibacterial fecal specimen was installed in the abdominal cavities of 80 rats. These animals were randomized to three groups: group 1 (n = 32), no intervention; group 2 (n = 24), conventional; group 3 (n = 24), laparoscopic lavage. At 1, 2, and 8 hours after the surgical intervention, animals were killed and autopsied. The main outcome measures were bacteremia, interleukin-6 (IL-6) in plasma and ascites, changes in the blood count, and myeloperoxidase (MPO) activity in lung, liver, kidney, and pancreas. Differences of bacteremia were not found. In the ascites a marked increase in IL-6 was observed after 8 hours, which was lower in the treatment groups than in the controls (p <0.025). MPO activity as a measure of the granulocytes present in the tissue showed significant changes only in lung tissue. Two hours after the surgical intervention, the MPO in the lung in the laparoscopy group was significantly lower than that in the controls and the laparotomy group. In conclusion, conventional and laparoscopic lavage reduce inflammation. In this model, laparoscopic lavage with a CO(2) pneumoperitoneum appeared to have no negative influence on the inflammatory reaction during the early postoperative phase. Reduced neutrophil sequestration in lung tissue following laparoscopic lavage reflects the lower level of trauma caused by laparoscopy.

Introduction: Extrapontine myelinolisis is a rare condition caused by severe hydroelectrolytic disorders. Following an initial stage of diffuse encephalopathy, the neurological sequelae are usually of diffuse cognitive deficits and extrapyramidal or cortico-bulbo-spinal disorders. We report a case of extrapontine myelinolisis following hypertonic peritoneal lavage due to rupture of a hydatid cyst of the liver (HCL), which was followed by a syndrome of isolated amnesia due to bilateral hippocampal lesions., Clinical Case: Following rupture of a HCL a 37 year old man was treated by peritoneal lavage with hypertonic saline solution. In the immediate postoperative period he had a prolonged confusion state associated with natremia of 176 mg/dl, which was corrected in less than 24 hours. Seven days later the patient had an apathy-inattention frontal syndrome. Six weeks later, and lasting until three months after operation, he had a selective memory deficit in learning tests (of the Barcelona-PIENC series of tests) with normality (29/30) in the MMST. On magnetic resonance there were hyperintense images in T2 in both hippocampus, insulas and corpus callosum., Conclusions: Generally caused by rapidly corrected hyponatremia, isolated hyponatremia or hypernatremia may also lead to extrapontine myelinolisis. However, we have found no report of extrapontine myelinolisis due to rupture of HCL and treatment with hypertonic peritoneal lavage. The neurological sequelae of extrapontine myelinolisis are usually global cognitive deficits, extra-pyramidal or cortico-bulbo-spinal disorders. Lesions seen on MR are usually found in the basal ganglia, thalamus or corpus callosum (with or without involvement of the pons). We have found no descriptions of bilateral hippocampal lesions causing selective memory deficits in this condition. Treatment by hypertonic peritoneal lavage for ruptured HCL may cause severe hydro-electrolytic alterations which may lead to myelinolisis of the CNS. We report of a case with bilateral hippocampal lesions and selective memory deficit, not previously described within the clinical spectrum of extrapontine myelinolisis.

Background: Adenosine exerts actions which may be beneficial in treating diseases of the gastrointestinal tract. However, administered systemically, adenosine causes a 'stress reaction' and may adversely affect blood pressure and cardiac and renal function., Aim: To determine whether peritoneal lavage with adenosine provides pharmacological levels of adenosine in the intestines without elevating adenosine levels in the systemic circulation., Methods: Rats received an intramesenteric artery infusion of angiotensin II (30 ng/min) plus methoxamine (3 microg/min) to reduce mesenteric blood flow by approximately 60%, and adenosine solutions were instilled into the abdominal cavity. In a second study, microdialysis probes were placed in the mesenteric vein and aortic arch of rats, and the peritoneal cavity was continuously lavaged with adenosine solutions., Results: High concentrations (10(-3)M) of adenosine normalized the mesenteric blood flow without affecting blood pressure or heart rate. High concentrations of adenosine (10(-3)M) induced micromolar levels of adenosine and inosine in the mesenteric vein, without affecting adenosine or inosine levels in the aorta., Conclusions: Peritoneal lavage with high concentrations of adenosine provides pharmacological levels of adenosine in the gastrointestinal tract without systemic side-effects. Peritoneal lavage with high concentrations of adenosine may be useful for the treatment of a number of diseases of the gastrointestinal tract.