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Objective:To investigate the influencing factors of surgical site infection (SSI) after abdominal surgery.Methods:The retrospective cross-sectional study was conducted. The clinical data of 567 patients undergoing abdominal surgery in 6 medical centers, including 445 cases in the Zhengzhou Central Hospital Affiliated to Zhengzhou University, 54 cases in the the First Affiliated Hospital of Zhengzhou University, 49 cases in the Shangqiu First People's Hospital, 10 cases in the Luoyang Central Hospital, 5 cases in the First Affiliated Hospital of Henan University of Science and Technology and 4 cases in the Henan Provincial People's Hospital, from June 1 to June 30, 2020 were collected. There were 284 males and 283 females, aged (51±18)years. Observation indicators: (1) incidence of SSI after surgery; (2) influencing factors of SSI. Follow-up was conducted using outpatient examination and telephone interview to detect the incidence of SSI. Patients without implant were followed up within postoperative 30 days, and patients with implant were followed up within postoperative 1 year. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measure-ment data with skewed distribution were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was performed using the chi-square test or Fisher exact probability. Univariate analysis was performed using the corresponding statistical methods. Multivariate analysis was performed using the Logistic stepwise regression model advance method. Results:(1) Incidence of SSI after surgery. All the 567 patients were followed up after surgery as planned. There were 27 cases with SSI after surgery including 9 cases with superficial incision infection, 9 cases with deep incision infection, 9 cases with organ/gap infection. Of the 27 cases with SSI after surgery, 18 cases with positive results of incisional microbial culture including 8 cases with positive results of Escherichia coli, 6 cases with positive results of Klebsiella pneumonia, 3 cases with positive results of Enterococcus faecium and 1 case with positive result of Pseudomonas aeruginosa. (2) Influencing factors of SSI. Results of univariate analysis showed that age, preoperative hemoglo-bin, preoperative albumin, preoperative fasting blood glucose, preoperative intestinal preparation, surgical type, surgical site, surgical incision type, duration of intensive cure unite, duration of post-operative hospital stay, duration of total hospital stay, operation time, hospital expense were related factors affecting the incidence of SSI of patients undergoing abdominal surgery ( χ2=40.12, Z=?4.22, ?2.21, ?4.75, χ2=7.07, 16.43, 38.06, 17.50, Z=?4.43, ?4.42, ?7.14, ?7.15, ?5.90, P<0.05) and the American Association of Anesthesiologists Classification, preoperative oral antibiotics, surgical methods and postoperative intensive care unit stay were related factors affecting the incidence of SSI of patients undergoing abdominal surgery ( P<0.05). Results of multivariate analysis showed that age, preopera-tive fasting blood glucose, preoperative intestinal preparation, surgical type, surgical site as appendix and rectum, surgical methods, surgical incision type as infective incision and polluted incision, operation time were independent factors affecting the incidence of SSI of patients undergoing abdo-minal surgery ( odds ratio=7.69, 1.21, 0.27, 5.82, 5.19, 19.08, 0.23, 27.76, 4.97, 1.01, 95% confidence intervals as 2.04?28.95, 1.04?1.41, 0.08?0.94, 1.36?24.85, 1.10?24.43, 4.48?81.25, 0.06?0.87, 2.54?303.53, 1.12?22.14, 1.01?1.02, P<0.05). Conclusion:Age, preoperative fasting blood glucose, preoperative intestinal preparation, surgical type, surgical site as appendix and rectum, surgical methods, surgical incision type as infective incision and polluted incision, operation time are independent factors affecting the incidence of SSI of patients undergoing abdominal surgery.
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Objective: To investigate the efficacy of fistula stent made by 3D printing technique in the treatment of enteroatmospheric fistula. Methods: A descriptive case series study was carried out.@*INCLUSION CRITERIA@#(1) patients with open abdomen; (2) patients with enteroatmospheric fistula.@*EXCLUSION CRITERIA@#(1) patient with two or more fistulas; (2) distal obstruction; (3) bowel stenosis over 50%. According to above criteria, 17 EAF patients admitted to the General Surgery Department of Jinling Hospital from June 2019 to January 2020 were retrospectively included in study. Based on the intestinal radiography, CT reconstruction and finger exploration, the size of fistula, the diameter of the intestinal tube and the angle of the intestinal lumen around the fistula were assessed. The 3D printing fistula stent was designed and established based on estimated data, and then placed through the fistula.@*OUTCOME MEASUREMENTS@#(1) success rate of stent implantation; (2) outflow of intestinal contents after implantation; (3) tolerated exercise time; (4) receiving definite operation time for intestinal fistula; (5) time to recovery of enteral nutrition. The t-test was used to compare the outflow amount of intestinal content before and after the stent implantation and the tolerated exercise time. The changes of the outflow amount of intestinal content and tolerated exercise time were analyzed by repeated measurement ANOVA. Results: Seventeen EAF patients with open abdomen included 13 males and 4 females. All the patients successfully received intestinal fistula stent implantation. Gastrointestinal angiography 2 days after implantation showed that the digestive tract was unobstructed, and the stent was successfully kept in place until definite surgery. No stent implantation-related adverse reactions were found in patients undergoing definite intestinal fistula surgery. The average outflow amount of intestinal fluid within 7 days after implantation decreased from (702.7±198.9) ml/d to on the first day after implantation (45.8±22.4) ml/d on the 7th day(F=10.380, P<0.001). The ambulatory time and exercise time of patients continued to increase after stent implantation. The average tolerated exercise time within 14 days after stent implantation increased from (9.1±3.8) min/d to (106.9±21.8) min/d (F=41.727, P<0.001). Within 120 days after stent implantation, 15 patients successfully underwent definite surgery for intestinal fistula and reconstruction of abdominal wall. Patients needed a median (IQR) of 3 (2, 5) days to recover enteral nutrition. The average time from stent placement to surgery was (87.2±17.6) days. Two patients died of severe abdominal infection with multiple organ failure. Conclusion: 3D printing fistula stent can significantly and the outflow of intestinal contents and the difficulty of nursing, and help to restore enteral nutrition and rehabilitation exercise as soon as possible in EAF patients with open abdomen.
Subject(s)
Female , Humans , Male , Abdominal Wall , Intestinal Fistula/surgery , Printing, Three-Dimensional , Retrospective Studies , Stents , Treatment OutcomeABSTRACT
Intestinal organoids, also named "mini-guts", reconstitute sophisticated three-dimensional architecture recapitulating diversified intestinal epithelial cell types and physiology, which is driven by the proliferative and self-assembling characteristics of crypt stem cells. The initiation of organoids study relies on the identification of Lgr5+ crypt stem cells from different intestinal segments and the key role of EGF, Wnt, BMP/TGF-β, Notch signal pathways within the microenvironment during the cultivation process. Besides constituting polarized crypt-villus structures, these "mini-guts" exhibit various effective functions of intestinal epithelium. Since 2009 when the culture system of small intestinal organoids was established by Sato et al, intestinal organoids excel conventional intestinal models depending on genetical mutation in multiple aspects and thus have become the hotspot among the research on intestinal diseases. Combined with genomics, material science and engineering, "mini-guts" have been widely applied to the research on intestinal development, intestinal transport physiology, epithelial barrier, pathogen-host interaction and the study on cystic fibrosis, infectious diarrhea, ulcerative colitis, Crohn's disease, intestinal cancer, etc. In this review, we summarize the new insights introduced by organoid into the research on intestinal diseases, and related research advances and applications.
Subject(s)
Humans , Intestinal Mucosa , Intestinal Neoplasms , Intestines , Organoids , Stem Cells , Tumor MicroenvironmentABSTRACT
Objective:To investigate the clinical value of cephalosporin combined with morinidazole in the prevention of surgical site infection (SSI) for gastrointestinal fistula.Methods:The retrospective cohort study was conducted. The clinicopathological data of 107 patients with gastrointestinal fistula who undergoing selective digestive tract reconstruction surgery in General Hospital of Eastern Theater Command from January to December 2017 were collected. There were 76 males and 31 females, aged from 18 to 79 years, with a median age of 46 years. Of 107 patients, 43 cases receiving cephalosporin for prevention of SSI were allocated into cephalosporin monotherapy group, 64 cases receiving cephalosporin combined with morinidazole were allocated into combination therapy group, respectively. Observation indicators: (1) incidence of SSI; (2) stratification; (3) pathogen culture results of SSI; (4) adverse drug reaction; (5) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect other complications of patients. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Incidence of SSI: 29 of 107 patients had postoperative SSI, including 15 cases with superficial SSI, 7 cases with deep SSI, and 7 cases with organ/space SSI. There were 18 cases of cephalosporin monotherapy group with SSI, including 7 cases with superficial SSI, 5 cases with deep SSI, and 6 cases with organ/space SSI. The above indicators were 11, 8, 2, 1 of combination therapy group, respectively. There was a significant difference in the overall SSI between the two groups ( χ2=7.925, P<0.05). There was also a significant difference in the organ/space SSI between the two groups ( P<0.05). There was no significant difference in the superficial SSI between the two groups ( χ2=0.305, P>0.05). There was no significant difference in the deep SSI between the two groups ( P>0.05). (2) Stratification: there were 10 cases and 33 cases with type Ⅱ incision and type Ⅲ incision in the 43 cases of cephalosporin monotherapy therapy group, respectively. The above indicators were 11 and 53 in the combination group, respectively. For the type Ⅱ incision, 1 patient of cephalosporin monotherapy group had SSI, and 2 cases of combination therapy group had SSI, showing no significant difference between the two groups ( P>0.05). For the type Ⅲ incision, 17 patient of cephalosporin monotherapy group had SSI, and 9 cases of combina-tion therapy group had SSI, showing a significant difference between the two groups ( χ2=11.499, P<0.05). (3) Pathogen culture results of SSI: of 29 patients with SSI, 21 were positive for bacterial culture, including 12 cases with single bacterial infection, 9 cases with mixed infection of multi-bacteria. A total of 33 strains were cultured. (4) Adverse drug reaction: there was no adverse drug reaction in the 107 patients. (5) Follow-up: 107 patients were followed up for 30 days after surgery. No complication occurred in the 107 patients. Conclusion:Cephalosporin combined with morini-dazole can be used to prevent the SSI for patients with gastrointestinal fistula.
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After adequate fluid resuscitation in the early stage of septic shock, excessive accumulation of fluid in the body leads to organ dysfunction, which prolongs hospitalization, mechanical ventilation time, and renal replacement therapy time, and is associated with poor prognosis. The fluid de-escalation therapy is an important fluid management strategy performed in the late stage of septic shock. It aims to clear excess fluid by restricting fluid infusion, using diuretics and renal replacement therapy to achieve a negative fluid balance. The fluid de-escalation therapy contributes to improve clinical outcome of septic shock patients and reduce the mortality. This review mainly discusses the current researches and application progress of the fluid de-escalation therapy of abdominal infection-induced septic shock through clarifying its origin, time and endpoint, method of the therapy, the relationship with the control of the source of abdominal infection and its impact on organ function and clinical outcome. Our study intends to provide guidance for the treatment of abdominal infection-induced septic shock in the late stage, and explore the novel research directions.
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Objective:To investigate the diagnosis and treatment for intra-abdominal fistula in China, and to explore the prognostic factors.Methods:A multi-center cross-sectional study was conducted based on the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections to collect the clinical data of patients with intra-abdominal fistula from 18 medical centers from January 1, 2018 to December 31, 2018, including basic information, medical records and prognosis.Results:A total of 106 patients were enrolled in this study, including 57 males and 49 females, with an average age of (48.0±17.8)years. The most common type of intra-abdominal fistula was entero-vesical fistula (34.0%), followed by entero-vaginal fistula (31.1%), entero-enteric fistula (26.4%) and multiple fistula (8.5%). The direct causes of intra-abdominal fistula were mainly surgical operation (66.0%), followed by spontaneous fistula due to Crohn′s disease (18.9%), radiation intestinal injury (11.3%), and 4 cases (3.8%) of unknown reasons. During the whole treatment, 95 patients received nutritional support therapy, mainly EN+ PN (75.8%). Finally, 86 patients (81.1%) received surgical treatment, with a healing rate of 95.3%. After surgery, 8.1% of patients developed surgical site infections (SSI), and 10.5% had a relapse of fistula. 20 patients (18.9%) were treated conservatively, with a self-healing rate of 80.0%. The overall mortality rate was 8.5%, and the highest mortality (15.2%) was found in entero-enteric fistula. Statistical analysis showed that the age ( t=-4.664, P<0.001), leucocyte level ( U=663.000, P=0.010), sepsis ( P=0.002) and multiple organ dysfunction syndrome (MODS) ( P=0.019) were higher in the death group than those in the healing group. Multivariate analysis suggested that advanced age ( OR=1.073, 95% CI: 1.008-1.141, P=0.026) and complications of sepsis ( OR=11.806, 95% CI: 1.064-131.048, P=0.044) were independent risk factors of the death for patients with intra-abdominal fistula. Conclusions:The overall mortality rate of intra-abdominal fistula is still high, and malignant tumor is the most common primary disease. Advanced age and sepsis are independent risk factors for death in patients with intra-abdominal fistula.
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Objective:To evaluate the value of lung ultrasound score (LUS) on predicting weaning outcome in patients with intro-abdominal infection (IAI) undergoing mechanical ventilation.Methods:Patients with IAI undergoing mechanical ventilation admitted to Research Institute of General Surgery of East War Zone Hospital and intensive care unit (ICU) of the First People's Hospital of Lianyungang from January to December in 2018 were included. The patients who satisfied weaning criteria were enrolled in the weaning process, which included spontaneous breathing trial (SBT) and extubation. They were divided into SBT success group and SBT failure group according to whether passed 120-minute SBT or not. LUS scores before and after SBT were compared between the two groups. The patients in the SBT success group were extubated, and they were divided into successful extubation group and failed extubation group for sub-group analysis according to whether re-intubation was needed in 48 hours after extubation. LUS score before extubation (at the end of SBT) and 48 hours after extubation (48 hours after extubation in the successful extubation group or before re-intubation in the failed extubation group) were compared. The receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of LUS score before SBT for SBT failure and LUS score before extubation for the failure.Results:A total of 76 patients with IAI undergoing mechanical ventilation were included. Twenty-three patients had duration of mechanical ventilation less than 48 hours, severe chronic obstructive pulmonary disease (COPD), tracheotomy or automatic discharge were excluded, and 53 patients were enrolled. SBT was failed in 9 patients, and successfully performed in 44 patients, of whom 23 patients with successful extubation, and 21 with failed extubation. The LUS scores before and after SBT in the SBT failure group were significantly higher than those in the SBT success group (before SBT: 13.22±1.99 vs. 10.79±1.64, t = -3.911, P = 0.000; after SBT: 19.00±1.12 vs. 13.41±1.86, t = -8.665, P = 0.000). ROC curve analysis showed that the area under ROC curve (AUC) of LUS score before SBT for predicting SBT failure was 0.82 [95% confidence interval (95% CI) was 0.67-0.98, P = 0.002]. When the optimum cut-off value was 12.5, the sensitivity was 66.7%, and the specificity was 84.1%. Sub-group analysis showed that the LUS scores before and after extubation in the failed extubation group were significantly higher than those in the successful extubation group (before extubation: 14.19±1.60 vs. 12.69±1.81, t = -2.881, P = 0.006; after extubation: 16.42±1.59 vs. 12.78±1.54, t = -7.710, P = 0.000). ROC curve analysis showed that the AUC of LUS score before extubation for predicting the failure was 0.81 (95% CI was 0.69-0.92, P = 0.000). When the optimum cut-off value was 13.5, the sensitivity was 80.0%, and the specificity was 65.2%. Conclusion:LUS score can effectively predict SBT outcome, risk of re-intubation after extubation in patients with IAI undergoing mechanical ventilation.
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Objective:To predict the efficacy and safety of cephalosporins antibiotics combined with metronidazole for intra-abdominal infections using Bayesian network meta analysis.Methods:Databases including PubMed, Embase, the Cochrane Library, CNKI, Wanfang database, VIP database were searched for literatures from January 1990 to May 2018 with the key words of ( "intraabdominal infections" [MeSH Terms]) AND ( "Cephalosporins*" [MeSH Terms]) AND ( "randomized controlled trial" [MeSH Terms]),腹腔感染,继发性腹膜炎,腹腔脓肿,头孢. The randomized controlled trials (RCTs) about comparison of efficacy and safety between cephalosporins antibiotics combined with metronidazole versus other antibiotics for intra-abdominal infections were received and included. Experimental group included patients who received cephalosporins antibiotics combined with metronidazole for intra-abdominal infections, and control group included patients who received other antibiotics for intra-abdominal infections. The primary outcomes were the clinical cure rates, microbial clearance rate and incidence of serious adverse drug reactions. R 3.6.2 software random Bayesian model was used for meta analysis. The Markov Chain Monte Carlo was used for direct evaluation and indirect prediction. The tracing method, density plotting and leverage figure method were used to evaluate the model convergence and stability. No closed loop formed between intervention measures, so there was no need to evaluate consistency.Results:(1) Document retrieval: a total of 18 available RCTs were enrolled. There were 6 792 patients, including 3 402 in the experimental group, 3 390 in the control group. (2) Results of Bayesian network meta analysis. ① The clinical cure rates of the third generation cephalosporins+ metronidazole, carbapenems were significantly lower than the fourth generation cephalosporins+ metronidazole [ odds ratio ( OR)=0.46, 0.61, 95% confidence interval( CI) as 0.26-0.81, 0.38-0.97, P<0.05]. There was no significant difference in the clinical cure rate between the fifth generation cephalosporins+ metronidazole and carbapenems ( OR=1.03, 95% CI as 0.59-1.80, P>0.05). ② The microbial clearance rates of the fifth generation cephalosporins+ metronidazole, carbapenems were significantly lower than the fourth generation cephalosporins+ metronidazole ( OR=0.84, 0.41, 95% CI as 0.73-0.98, 0.23-0.74, P<0.05). There was no significant difference in the microbial clearance rate between the fifth generation cephalosporins+ metronidazole and carbapenems ( OR=0.76, 95% CI as 0.27-1.80, P>0.05). ③ The incidence of serious adverse drug reactions was significantly lower for the third generation cephalosporins+ metronidazole, the fourth generation cephalosporins antibiotics+ cetronidazole, the fifth generation cephalosporins+ metronidazole, carbapenems, quinolones+ metronidazole, and tigecycline than for quinolones ( OR=0.13, 0.13, 0.14, 0.13, 0.15, 0.13, 95% CI as 0.03-0.50, 0.02-0.98, 0.02-0.75, 0.02-0.59, 0.02-0.78, 0.02-0.57, P<0.05). Compared with carbapenems, the third generation cephalosporins+ metronidazole, the fourth generation cephalosporins+ metronidazole, the fifth generation cephalosporins+ metronidazole had no significant difference in the incidence of serious adverse drug reactions ( OR=0.96, 1.00, 1.10, 95% CI as 0.52-1.60, 0.31-3.50, 0.49-2.30, P>0.05). (3) Ranking of the efficacy and safety. ① The ranking list for clinical cure rates of different therapeutic regimens showed from high to low as quinolones+ metronidazole, the fourth generation cephalosporins+ metronidazole, synthetic penicillins, the second generation cephalosporins+ metronidazole, the fifth generation cephalosporins+ metronidazole, carbapenems, the third generation cephalosporins+ metronidazole, tigecycline, quinolones. The corresponding ranking probabilities of above regimens were 51.73%, 35.72%, 22.57%, 31.37%, 24.98%, 32.82%, 34.69%, 29.05%, 72.36%, respectively. ② The ranking list for microbial clearance rates of different therapeutic regimens showed from high to low as quinolones+ metronidazole, the fourth generation cephalosporins+ metronidazole, the second generation cephalosporins+ metronidazole, synthetic penicillins, the fifth generation cephalosporins+ metronidazole, carbapenems, the third generation cephalosporins+ metronidazole, tigecycline, quinolones. The corresponding ranking probabilities of above regimens were 89.62%, 77.01%, 38.60%, 20.94%, 26.26%, 26.39%, 22.22%, 20.19%, 62.55%, respectively. ③ The ranking list for incidence of serious adverse drug reactions of different therapeutic regimens showed from high to low as quinolones, quinolones+ metronidazole, the fifth generation cephalosporins+ metronidazole, carbapenems, the third generation cephalosporins+ metronidazole, tigecycline, the fourth generation cephalosporins+ metronidazole. The corresponding ranking probabilities of above regimens were 96.21%, 30.46%, 21.09%, 25.27%, 27.26%, 19.45%, 31.69%, respectively. Conclusion:In the treatment of middle- and low-risk intra-abdominal infections, it is recommended to empirically use cephalosporins+ metronidazole instead of carbapenems.
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Intra-abdominal infection (IAI) is a deadly condition in which the outcome is associated with urgent diagnosis, assessment and management, including fluid resuscitation, antibiotic administration while obtaining further laboratory results, attaining precise measurements of hemodynamic status, and pursuing source control. This last item makes abdominal sepsis a unique treatment challenge. Delayed or inadequate source control is an independent predictor of poor outcomes and recognizing source control failure is often difficult or impossible. Further complicating issue in the debate is surrounding the timing, adequacy, and procedures of source control. This review evaluated and summarized the current approach and challenges in IAI management, which are the future research directions.
Subject(s)
Humans , Anti-Bacterial Agents/administration & dosage , Drainage , Fluid Therapy , Hemodynamics , Intraabdominal Infections/therapy , Laparoscopy , Laparotomy , Prognosis , SepsisABSTRACT
Objective@#To investigate the diagnosis and treatment for enterocutaneous fistula (ECF) in China, and to explore the prognostic factors of ECF.@*Methods@#A multi-center cross-sectional study was conducted based on the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections to collect the clinical data of ECF patients from 54 medical centers in 22 provinces/municipalities from January 1, 2018 to December 31, 2018. The clinical data included patient gender, age, length of hospital stay, intensive care unit (ICU) admission, underlying diseases, primary diseases, direct causes of ECF, location and type of ECF, complications, treatment and outcomes. All medical records were carefully filled in by the attending physicians, and then re-examined by more than two specialists. The diagnosis of ECF was based on the clinical manifestations, laboratory/imaging findings and intraoperative exploration.@*Results@#A total of 1521 patients with ECF were enrolled, including 1099 males and 422 females, with a median age of 55 years. The top three primary diseases of ECF were malignant tumors in 626 cases (41.2%, including 540 gastrointestinal tumors, accounting for 86.3% of malignant tumors), gastrointestinal ulcers and perforations in 202 cases (13.3%), and trauma in 157 cases (10.3%). The direct causes of ECF were mainly surgical operation in 1194 cases (78.5%), followed by trauma in 156 (10.3%), spontaneous fistula due to Crohn′s disease in 92 (6.0%), radiation intestinal injury in 41 (2.7%), severe pancreatitis in 20 (1.3%), endoscopic treatment in 13 (0.9%) and 5 cases (0.3%) of unknown reasons. All the patients were divided into three groups: 1350 cases (88.7%) with simple ECF, 150 (9.9%) with multiple ECF, and 21 (1.4%) with combined internal fistula. Among the patients with simple ECF, 438 cases (28.8%) were jejuno-ileal fistula, 313 (20.6%) colon fistula, 170 (11.2%) rectal fistula, 111 (7.3%) duodenal fistula, 76 (5.0%) ileocecal fistula, 65 (4.3%) ileocolic anastomotic fistula, 55 (3.6%) duodenal stump fistula, 36 (2.4%) gastrointestinal anastomotic fistula, 36 (2.4%) esophagogastric/esophagojejunal anastomotic fistula, 29 (1.9%) gastric fistula and 21 (1.4%) cholangiopancreatiointestinal. Among all the simple ECF patients, 991 were tubular fistula and 359 were labial fistula. A total of 1146 patients finished the treatment, of whom 1061 (92.6%) were healed (586 by surgery and 475 self-healing) and 85 (7.4%) died. A total of 1043 patients (91.0%) received nutritional support therapy, and 77 (6.7%) received fistuloclysis. Infectious source control procedures were applied to 1042 patients, including 711 (62.0%) with active lavage and drainage and 331 (28.9%) with passive drainage. Among them, 841 patients (73.4%) underwent minimally invasive procedures of infectious source control (replacement of drainage tube through sinus tract, puncture drainage, etc.), 201 (17.5%) underwent laparotomy drainage, while 104 (9.1%) did not undergo any drainage measures. A total of 610 patients (53.2%) received definitive operation, 24 patients died within postoperative 30-day with mortality of 3.9% (24/610), 69 (11.3%) developed surgical site infection (SSI), and 24 (3.9%) had a relapse of fistula. The highest cure rate was achieved in ileocecal fistula (100%), followed by rectal fistula (96.2%, 128/133) and duodenal stump fistula (95.7%,44/46). The highest mortality was found in combined internal fistula (3/12) and no death in ileocecal fistula. Univariate prognostic analysis showed that primary diseases as Crohn′s disease (χ2=6.570, P=0.010) and appendicitis/appendiceal abscess (P=0.012), intestinal fistula combining with internal fistula (χ2=5.460, P=0.019), multiple ECF (χ2=7.135, P=0.008), esophagogastric / esophagojejunal anastomotic fistula (χ2=9.501, P=0.002), ECF at ileocecal junction (P=0.012), non-drainage/passive drainage before the diagnosis of intestinal fistula (χ2=9.688, P=0.008), non-drainage/passive drainage after the diagnosis of intestinal fistula (χ2=9.711, P=0.008), complicating with multiple organ dysfunction syndrome (MODS) (χ2=179.699, P<0.001), sepsis (χ2=211.851, P<0.001), hemorrhage (χ2=85.300, P<0.001), pulmonary infection (χ2=60.096, P<0.001), catheter-associated infection (χ2=10.617, P=0.001) and malnutrition (χ2=21.199, P<0.001) were associated with mortality. Multivariate prognostic analysis cofirmed that sepsis (OR=7.103, 95%CI:3.694-13.657, P<0.001), complicating with MODS (OR=5.018, 95%CI:2.170-11.604, P<0.001), and hemorrhage (OR=4.703, 95%CI: 2.300-9.618, P<0.001) were independent risk factors of the death for ECF patients. Meanwhile, active lavage and drainage after the definite ECF diagnosis was the protective factor (OR=0.223, 95%CI: 0.067-0.745, P=0.015).@*Conclusions@#The overall mortality of ECF is still high. Surgical operation is the most common cause of ECF. Complications e.g. sepsis, MODS, hemorrhage, and catheter-associated infection, are the main causes of death. Active lavage and drainage is important to improve the prognosis of ECF.
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Objective@#To understand the prevalence, diagnosis and treatment of chronic critical illness (CCI) in China.@*Methods@#The clinical data of 472 adult patients admitted to ICU in 53 hospitals, including basic information, disease-related data, nutrition program, etc., were collected on May 10, 2019, by means of multi-center cross-sectional study. If surgical intervention was needed or the occurrence of the disease was directly related to the surgery, ICU patients were regarded as surgical ICU cases (n=211). In this study, the diagnostic criteria for CCI were: (1) admission to ICU >14 days;(2) combined with persistent organ dysfunction. The prevalence,distribution and treatment of CCI and surgery-related CCI were recorded and analyzed. The Mann-Whitney U test, chi-square test or Fisher exact test were used for comparative analysis.@*Results@#Among the 472 ICU patients from 53 hospitals, 326 were male (69.1%) and 146 were female (30.9%). The prevalence of CCI was 30.7% (145/472). Among 211 surgery-related ICU patients, 57 developed CCI with a prevalence of 27.0%. As compared to non-CCI patients, higher APACHE II score [median (IQR) 13.5 (10.0, 18.3) vs. 11.0 (7.0, 16.0), U=2970.000, P=0.007], higher Charlson comorbidity index [median (IQR) 4.0 (2.0, 7.0) vs. 3.0 (1.0, 5.0), U= 3570.000, P=0.036] and higher ratio of breath dysfunction [68.4% (39/57) vs. 48.1% (74/154), χ2=6.939, P=0.008] and renal dysfunction [42.1% (24/57) vs. 18.2% (28/154), χ2=12.821, P<0.001] were found in surgery-related CCI patients. While SOFA score, Glasgow coma score and other visceral function were not significantly different between surgery-related CCI and non-CCI patients (all P>0.05). NUTRIC score showed that surgery-related CCI patients had higher nutritional risk [43.9% (25/57) vs. 26.6%(41/154), U=5.750, P=0.016] and higher ratio of mechanical ventilation [66.7% (38/57) vs. 52.3% (79/154), χ2=3.977, P=0.046] than non-CCI patients. On the survey day, the daily caloric requirements of 50.2% (106/211) of surgery-related ICU patients were calculated according to the standard adult caloric intake index (104.6 to 125.5 kJ·kg-1·d-1, 1 kJ=0.239 kcal), and the daily caloric requirements of 46.4% (98/211) of patients were calculated by physicians according to the severity of the patient′s condition. 60.2% (127/211) of nutritional support therapy was enteral nutrition (including a combination of enteral and parenteral nutrition), while the remaining patients received parenteral nutrition (24.6%, 52/211), simple glucose infusion (9.0%, 19/211), or oral diet (6.2%, 13/211). The target calorie of CCI group was 104.6 (87.9, 125.5) kJ·kg-1·d-1, and the actual calorie intake accounted for 0.98 (0.80, 1.00) of the target calory. In the non-CCI group, the target calorie was 104.6 (87.9, 125.5) kJ·kg-1·d-1, and the actual calorie consumed accounted for 0.91 (0.66, 1.00) of the target calorie. There was no statistically significant difference between two groups (P=0.248, P=0.150).@*Conclusion@#The prevalence of CCI and surgery-related CCI in ICU is high, along with severe complications, respiratory and renal dysfunction and mechanical ventilation. Surgical patients admitted to ICU are at high nutritional risk, and active and correct nutritional support is essential for such patients.
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De-escalation strategy is the gradual transition of various complex, expensive, high-risk but effective treatments for critically ill patients to simple, safe, physiological but still effective ones. Chronic critical illness refers to patients suffering severe disease or surgical hit who later shift into a chronic state of relapse or even aggravation and stay in the intensive care unit for extended period. Risk factors for surgical related chronic critical illness include advanced age, malnutrition, multiple organ dysfunction and multiple hits. During the treatment of critically ill patients, the strategy of de-escalation therapy should always be implemented, including rational use of antibiotics, de-escalation of liquid therapy (i.e. de-resuscitation), timely removal of ventilator, rapid introduction and with drawal of continuous renal replacement measures, parenteral + enteral nutrition support therapy and timely cessation of sedation.
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Source control should be performed as soon as possible once the diagnosis of intra-abdominal infection made. Surgical intervention should be considered when resuscitating the intra-abdominal infection with sepsis or septic shock and percutaneous abscess drainage, laparotomy or open abdominal therapy could be considered according to the sepsis severity. Treatment failure may be diagnosed if there is no any improvement in the systematic inflammatory reaction and multiple organ dysfunction. Interleukin 6 and procalcitonin combined with blood white cell count and C-reactive protein could reflect the systematic inflammatory reaction and Sequential Organ Failure Assessment can evaluate if there is any improvement of organ function. Bilirubin is a sensitive indicator of liver function in intra-abdominal infection and its persistent increasing usually means the deterioration of liver function. Once the treatment failure is made, the re-intervention should be performed as soon as possible and B ultrasound or CT should be done before operation to define the precise infected focus. The bacteria information should be retrieved before or during the intervention to guide the postoperative antibiotics usage.
ABSTRACT
Source control should be performed as soon as possible once the diagnosis of intra-abdominal infection made.Surgical intervention should be considered when resuscitating the intra-abdominal infection with sepsis or septic shock and percutaneous abscess drainage,laparotomy or open abdominal therapy could be considered according to the sepsis severity.Treatment failure may be diagnosed if there is no any improvement in the systematic inflammatory reaction and multiple organ dysfunction.Interleukin 6 and procalcitonin combined with blood white cell count and C-reactive protein could reflect the systematic inflammatory reaction and Sequential Organ Failure Assessment can evaluate if there is any improvement of organ function.Bilirubin is a sensitive indicator of liver function in intra-abdominal infection and its persistent increasing usually means the deterioration of liver function.Once the treatment failure is made,the re-intervention should be performed as soon as possible and B ultrasound or CT should be done before operation to define the precise infected focus.The bacteria information should be retrieved before or during the intervention to guide the postoperative antibiotics usage.
ABSTRACT
Sepsis is one of the most important factors leading to death in critically ill patients. Neutrophils are the main effector cells that play an immune response during sepsis. In addition to exerting chemotaxis and phagocytosis, neutrophils are also capable of releasing neutrophil extracellular traps (NETs) composed of double-stranded DNA and antibacterial proteins embedded in DNA. The persistent over-formation of NETs in sepsis will cause thrombosis and multiple organ dysfunction (MOD). Gut as the initial organ of MOD, sepsis and intestinal barrier damage is an important cause of MOD. Studies have confirmed that NETs are closely related to intestinal barrier damage, and excessive formation of NETs in the intestine can cause persistent inflammation of the intestinal mucosa, leading to intestinal dysfunction. This article outlines the latest advances in NETs in sepsis and intestinal function, providing new directions for the early diagnosis and treatment of sepsis.
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OBJECTIVE: To understand the current status of surgical site infection(SSI)after emergency abdominal surgery(EAS) in China,and to discuss the risk factors.METHODS: The study included 293 adult patients who underwent EAS in 26 hospitals in China in May 2018. The basic information, perioperative data, and microbial culture results of infected incisions were collected prospectively. The primary outcome measure was the incidence of surgical site infection within 30 days after surgery. Secondary outcome variables were postoperative hospital stay,ICU occupancy,ICU stay,treatment costs,and postoperative30-day mortality.RESULTS: Twenty-two(7.5%) patients developed SSI after surgery.The main pathogen of SSI is Escherichia coli [culture positive rate was 36.4%(8/22)]. Patients with SSI had a significantly longer overall hospital stay and ICUstay,and ICU occupancy and treatment were significantly higher. Multivariate logistic regression analysis showed thatmales(P=0.030) and operative time(P=0.007) were risk factors for SSI. Laparoscopic surgery(P=0.022)was aprotective factor for SSI.CONCLUSION: The incidence of SSI after EAS in China is 7.5%,and SSI leads to a significantincrease in the medical burden of patients. Choosing laparoscopic surgery can reduce the incidence of SSI after EAS.Controlling preoperative blood glucose may have positive significance in preventing SSI after EAS.
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OBJECTIVE:To analyze the clinical characteristics and prognosis of Crohn's patients with gastrointestinal fistulas.METHODS:The data of 273 patients with gastrointestinal fistulas who were registered in GI Fistula Center, Department of Surgery, Jinling Hospital from January 2001 to June 2015 were retrospectively reviewed and the clinical features,characteristics of gastrointestinal fistulas, medication plan and outcome of the patients were analyzed.RESULTS:The ratio of male to female was 2.5:1.The mean onset age was 29(22,40)years. The mean diagnosis age was 31(25,42)years. The averageage between onset to diagnosis was22(8,31)months. The most common initial symptoms were abdominal pain(78.0%), diarrhea(28.9%) and fever(26.0%). The most common lesion locations were terminal ileum(56.8%). The most common behavior of disease were penetrating(54.9%), followed by stricturing(42.1%), inflammatory(2.9%) and perianal disease(19.0%). 442 patients developed GI, including intestinal cutaneous fistulas(73.9%) and intestinal fistulas(26.1%).The most type of intestinal cutaneousfistulas were ileocecal anastomotic fistula.The most type of intestinal fistulas were entero-vesical fistulas. Enteral nutrition(91.9%) and parenteralnutrition(72.9%) combined with sulfasalazine(57.9%) and tripterygium glycosides(48.0%) were the most commonly used drugs. A total of 227(83.1%)patientsreceived antibiotics due to infectious complications. Β-lactam(77.6%) and nitroimidazoles(56.0%) were the most common antibi-otics. All the patients had received 625 cases of operations. The cumulative operative rates of 1 year, 3 years and 5 years after diagnosis were 34.4%, 59.0%and 63.0%. 9(3.3%)patients died during the research.The cumulative survival rates were 98.5%, 97.8%,and 96.7% at 1 year, 3 years and 10 years after diagnosis.CONCLUSION:Compared with the literature of western and other Asian countries, there are some differences in sex ratio, lesion locations, operative rates and mortality ratesamong Crohn's disease patients with GI fistula. Further followup and in-depth study are needed.
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Open abdomen therapy (OA) is a breakthrough in treating abdominal trauma and infections. Enterorrhexis and entero-atmospheric fistula are both severe complications of OA and impact the therapeutic effect of OA seriously. To solve this problem, the pathophysiology of the OA wound formation and development, and the early protection measures of the OA wound are studied. Many biomaterials were developed, including autologous fibrin glue, electrospinning nanofiber membrane and hydrogel, to realize the target of early protection of the OA wound through hemostasis, anti-infection, antioxidation, and proliferation promoting.
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Objective To explore the predictive value of prognostic nutritional index (PNI) in surgical site infections (SSIs) for intestinal fistula patients undergoing bowel resections.Methods Clinical data of 290 gastrointestinal fistula patients who underwent intestinal resections between 2012 and 2015 were retrospectively reviewed.Univariate and multivariate analyses were conducted to identify risk factors for SSIs,and receiver operating characteristic (ROC) curve was used to quantify the effectiveness of PNI.Results SSIs were diagnosed in 99 (34.1％) patients.ROC curve analysis defined a PNI cut-off level of 45 corresponding to postoperative SSIs (area under the curve =0.72,76％ sensitivity,55％ specificity).Furthermore,a multivariate analysis indicated that the PNI ＜ 45 (OR:2.24,95％ CI:1.09-4.61,P =0.029) and preoperative leukocytosis (OR:3.70,95 ％ CI:1.02-13.42,P =0.046) were independently associated with postoperative SSIs.Conclusions Preoperative PNI is useful to predict SSIs in intestinal fistulae patients after enterectomies.
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Objective To investigate the predictive value of non-thyroidal illness syndrome (NTIS) before definitive operation on postoperative surgical site infection (SSI) in patients with enterocutaneous fistula (ECF).Methods The retrospective case-control study was conducted.The clinical data of 264 ECF patients (181 with euthyroidism and 83 with NTIS) who underwent definitive operation in the Nanjing General Hospital of Nanjing Military Command between April 2014 and November 2016 were collected.After definitive operation,86 with SSI and 178 without SSI were respectively allocated into the SSI group and non-SSI group.Observation indicators:(1) risk factor analysis of postoperative SSI;(2) effect of preoperative NTIS on postoperative SSI;(3) predictive power of serum free triiodothyronine 3 (FT3) level on postoperative SSI.Measurement data with normal distribution were represented as x-± s and was analyzed using the t test.Count data were described as absolute number or percentage,and were analyzed using the chi-square test.The comparison of ordinal data was done by the nonparamentric test.The multivariate analysis was done using the logistic regression model.The receiver operating characteristic (ROC) curve was drawn,and area under the curve (AUC) was calculated for analyzing predictive power of serum FT3 level on postoperative SSI.Results (1) Risk factor analysis of postoperative SSI:cases with volume of preoperative intestinal fluid loss through fistula stoma ＜ 200 mL/24 hours,from 200 to 500 mL/24 hours and ＞ 500 mL/24 hours,preoperative hemoglobin (Hb) level,cases with surgical site located in stomach and duodenum,small intestine,ileocolon and colorectum,cases with open surgery and laparoscopic surgery were respectively 65,15,6,(119±36)g/L,5,50,31,36,58,28 in the SSI group and 135,27,16,(125±39)g/L,11,91,53,71,127,51 in the non-SSI group,with no statistically significant difference between groups (x2 =0.471,t =1.202,x2 =0.332,0.422,P＞0.05).Cases with preoperative single.and multiple fistula stoma,serum albumin (Alb) level,cases with preoperative NTIS,volume of intraoperative blood loss ＜ 300 mL and ≥ 300 mL,operation duration ＜ 3 hours and ≥ 3 hours were respectively 57,29,(35±.8)g/L,36,67,19,53,33 in the SSI group and 146,32,(37±9)g/L,47,161,17,140,38 in the non-SSI group,with statistically significant differences between groups (x2 =8.089,t =2.422,x2 =6.426,7.746,8.547,P＜0.05).Results of multivariate analysis showed that preoperative multiple intestinal fistula and NTIS were independent factors affecting occurrence of postoperative SSI in ECF patients (odds ratio =1.873,2.464,95％ confidence interval:1.052-2.671,1.120-4.392).(2) Effect of preoperative NTIS on postoperative SSI:incidence of preoperative multiple intestinal fistula,proportion of cases with preoperative enteral nutrition time ＞3 months,incidence of postoperative SSI,postoperative superficial and deep incision infection rates and organ/space infection rate were respectively 31.3％ (26/83),72.3％ (60/83),43.4％ (36/83),9.6％ (8/83),21.7％(18/83),7.2％ (6/83) in patients with NTIS and 19.3％(35/181),57.5％(104/181),27.6％(50/181),11.6％(21/181),3.9％(7/181),8.8％ (16/181) in patients with euthyroidism,with statistically significant differences in incidence of multiple intestinal fistula,proportion of cases with preoperative enteral nutrition time ＞ 3 months,incidence of postoperative SSI,superficial and deep incision infection rates (x2 =4.603,5.319,6.426,4.256,4.377,P＜0.05),and no statistically significant difference in organ/space infection rate (x2=0.193,P＞0.05).(3) Predictive power of serum FT3 level on postoperative SSI:the ROC curve showed that optimal cut-off point of serum FT3 predicting postoperative SSI was 3.5 pmol/L,AUC,sensibility and specificity were respectively 0.75,72.6％ and 68.7％.Conclusion The presence of NTIS is associated with occurrence of postoperative SSI in patients with ECF before definitive operation,and optimal cut-off point of serum FT3 predicting postoperative SSI is 3.5 pmol/L.