Eficacia de la impronta citológica peritoneal para decidir cuándo detener los lavados peritoneales programados / Efficacy of Peritoneal Cytological Imprinting in Deciding When to Stop Scheduled Peritoneal Lavages

Introducción: La no existencia de un parámetro preestablecido que permita determinar el momento preciso para suspender los lavados peritoneales programados, conlleva a que muchas veces se realice un número insuficiente de ellos, o tal vez estos se prolonguen de forma innecesaria y aumentan las probabilidades de fallecimiento del paciente. Objetivo: Determinar la eficacia de la impronta citológica peritoneal para decidir cuándo detener los lavados peritoneales programados. Métodos: Se realizó un estudio descriptivo de exactitud diagnóstica, en una serie de casos, con recogida prospectiva de datos desde enero de 2010 hasta diciembre de 2014, en el Hospital Provincial Clínico-Quirúrgico Docente "Celia Sánchez Manduley. La muestra quedó conformada por 42 pacientes que fueron tratados por peritonitis secundaria persistente. Se clasificaron según cuatro categorías de correlación y se tomó como estándar de referencia a la biopsia por parafina. Resultados: Las muestras con inflamación aguda peritoneal y curación de la inflamación peritoneal se identificaron correctamente en 39/42 casos, por lo tanto, el porcentaje predictivo global de la impronta citológica fue del 92,86 por ciento. La sensibilidad en el diagnóstico de inflamación aguda peritoneal fue del 100 por ciento, la especificidad del 92,68 por ciento, el valor predictivo positivo fue del 24,99 por ciento y el valor predictivo negativo del 100 por ciento. Las razones de verosimilitudes positiva y negativa fueron 13,67 y 0, respectivamente. El coeficiente (κ) fue de 0,376. Conclusiones: La impronta citológica peritoneal constituye un método diagnóstico eficaz para descartar inflamación aguda peritoneal cuando el resultado es negativo y se consideró de gran utilidad para detener los lavados peritoneales programados(AU)

Introduction: The lack of a pre-established parameter that allows determining the precise moment to suspend the scheduled peritoneal lavages, often leads to performing insufficient number of them, or perhaps these are unnecessarily prolonged, increasing the probability of the patient´s death. Objective: To determine the efficacy of peritoneal cytological imprinting in deciding when to stop scheduled peritoneal lavages. Methods: A descriptive study of diagnostic accuracy was carried out, in a series of cases, with prospective data collection in the five-year period from 2010 to 2014 at Celia Sánchez Manduley Provincial Clinical-Surgical Teaching Hospital. The sample was made up of 42 patients who were treated for persistent secondary peritonitis. They were classified according to four correlation categories, taking paraffin biopsy as reference standard. Results: Samples with acute peritoneal inflammation and healing of peritoneal inflammation were correctly identified in 39/42 cases. Therefore, the global predictive percentage of the cytological imprint was 92.86 percent. The sensitivity in the diagnosis of acute peritoneal inflammation was 100 percent, the specificity was 92.68 percent, the positive predictive value was 24.99 percent, and the negative predictive value was 100 percent. The positive and negative likelihood ratios were 13.67 and 0, respectively. Cohen's kappa coefficient (κ) was 0.376. Conclusions: The peritoneal cytological imprint is an effective diagnostic method to rule out acute peritoneal inflammation when the result is negative and it was considered very useful to stop scheduled peritoneal lavages(AU)

Progress in gastric cancer with positive peritoneal cytology / 中华胃肠外科杂志

Gastric cancer with positive peritoneal cytology is a hotspot in the study of gastric cancer, and its prognosis is poor. Intraperitoneal free cancer cells may be associated with cancer cells migration, invasion and metastasis. Tumor T stage, peritoneal metastasis, lymph node metastasis, low histological differentiation, linitis plastica, adenocarcinoma of esophagogastric junction, and operation are the clinicopathological risk factors of gastric cancer with positive peritoneal cytology. Currently, the acquisition of free cancer cells is mainly through diagnostic laparoscopy combined with peritoneal lavage, and cytopathological examination is gold standard for diagnosis. Its treatment strategies are not in consensus, including preoperative chemotherapy combined with radical resection, postoperative chemotherapy and peritoneal local treatment, which can prolong the survival of patients. At present, postoperative chemotherapy is often used in China, and the best treatment strategies remain to be further studied.

Safety and effectiveness of laparoscopic peritoneal lavage in Hinchey III diverticulitis / Segurança e eficácia da lavagem peritoneal laparoscópica na diverticulite Hinchey III

Abstract Introduction: The management of Hinchey III diverticulitis has been subject to investigation over the years. Hartmann's procedure is widely referred as the standard treatment. However, this option is associated with relevant morbidity and mortality which motivated the arise of alternative interventions such as the laparoscopic peritoneal lavage. Aim: The aim of this review is to synthesize the evidence on the safety and effectiveness of laparoscopic peritoneal lavage in the management of diverticulitis with generalized purulent peritonitis in comparison to resection procedures. Materials and methods: The bibliographic research was conducted using the electronic database Medline from Pubmed. Of the 358 articles identified, our criterious selection resulted in a total of 27 articles for review. Results: Overall, laparoscopic lavage revealed low mortality rates with no remarkable differences between procedures. The non-randomized studies tended to show lower recurrence and morbidity rates comparatively to the latest RCTs, in the lavage groups, however, no significant differences have been found. Discussion and conclusion: In this review, laparoscopic peritoneal lavage proved to be safe and comparatively effective, although not superior to resection, reaching mixed results. We believe it can be applied as a damage control operation to treat or as a bridge to elective resection. Still, more studies are needed to determine indications and factors for the success of laparoscopic lavage.

Resumo Introdução: O tratamento da diverticulite por Hinchey III tem sido objeto de investigação ao longo dos anos. A operação tipo Hartmann é amplamente referida como o tratamento padrão. No entanto, esta opção está associada à morbilidade e mortalidade relevante, o que motivou o surgimento de intervenções alternativas, como a lavagem peritoneal laparoscópica. Objetivo: O objetivo desta revisão é sintetizar a evidência sobre a segurança e a eficácia da lavagem peritoneal laparoscópica no tratamento da diverticulite com peritonite generalizada purulenta em comparação com os procedimentos de ressecção. Materiais e métodos: A pesquisa bibliográfica foi realizada na base de dados eletrónica Medline da Pubmed. Dos 358 artigos identificados, a nossa seleção criteriosa resultou num total de 27 artigos para revisão. Resultados: No geral, a lavagem laparoscópica revelou baixas taxas de mortalidade sem diferenças significativas entre os procedimentos. Os estudos não randomizados tenderam a mostrar menores taxas de recorrência e morbilidade comparativamente aos últimos ensaios clínicos randomizados, nos grupos submetidos à lavagem, no entanto, nenhuma diferença significativa foi encontrada. Discussão e conclusão: Nesta revisão, a lavagem peritoneal laparoscópica mostrou-se segura e comparativamente eficaz, embora não superior à ressecção, não alcançando resultados constantes. Nós acreditamos que pode ser aplicada como um procedimento de controlo de danos para tratamento ou como ponte para cirurgia eletiva. Ainda assim, são necessários mais estudos para determinar indicações e fatores para o sucesso da lavagem laparoscópica.

Evaluating the effect of gentamicin-clindamycin lavage on post-operational pain and infection through laparoscopic colectomy surgery / Avaliação do efeito da lavagem com gentamicina-clindamicina sobre a dor e a infecção após colectomia laparoscópica

Abstract Introduction Peritoneal antibiotic or normal saline lavage is seen to be beneficial in order to reduce the pain or infection risk through laparoscopic surgeries. It can also be applied for laparoscopic colectomy surgeries. In this study, we have compared the effects of antibiotic solution lavage (gentamycin-clindamycin) with normal saline lavage in patients undergoing laparoscopic colectomy surgery. Method In this double-blind Randomized Controlled Trial (RCT), 40 patients undergoing laparoscopic colectomy surgery were divided into antibiotic and normal saline lavage groups (20 patients in each group). Post-operational pain, need for painkiller, white blood cells count, C-reactive protein level, duration of hospitalization and wound infection were compared in 30 days between the groups. Results Antibiotic lavage group had significantly less pain than the normal saline group (p < 0.05) through 3, 6, 12 and 24 h after surgery. C-reactive protein level, white blood cells count, painkiller use, and hospitalization duration were significantly lower in antibiotic group. However, there was no difference regarding wound or intra-abdominal infection between the both groups. Conclusion Using gentamicin-clindamycin peritonea lavage helps patients undergoing laparoscopic colectomy surgery in pain reduction, need for painkillers and hospitalization duration.

Resumo Introdução A lavagem peritoneal com antibiótico ou com soro fisiológico normal é benéfica para reduzir o risco de dor ou de infecção durante cirurgias laparoscópicas, além de poder ser aplicada também em colectomias laparoscópicas. Neste estudo, comparamos os efeitos da lavagem com solução antibiótica (gentamicina-clindamicina) e da lavagem com solução salina normal em pacientes submetidos à colectomia laparoscópica. Método Neste Ensaio Clínico Randomizado (ECR), controlado e duplo-cego, 40 pacientes submetidos à colectomia laparoscópica foram divididos em dois grupos (20 pacientes em cada grupo) para receberem antibiótico ou solução salina normal. Dor pós-operatória, necessidade de analgésico, contagem de leucócitos, nível de proteína C-reativa, tempo de internação e infecção da ferida foram comparados entre os grupos em 30 dias. Resultados De forma significativa, o Grupo Antibiótico apresentou menos dor que o Grupo Salina Normal (p < 0,05) em 3, 6, 12 e 24 horas após a cirurgia. O nível de proteína C-reativa, a contagem de leucócitos, o uso de analgésicos e o tempo de internação foram significativamente menores no Grupo Antibiótico. Porém, não houve diferença em relação à infecção da ferida ou intra-abdominal entre os dois grupos. Conclusão O uso da lavagem peritoneal com gentamicina-clindamicina ajuda a reduzir a dor, a necessidade de analgésicos e o tempo de internação de pacientes submetidos à colectomia laparoscópica.

Laparotomía abreviada y terapia de presión negativa para el cierre temporal del abdomen como tratamiento de la peritonitis diverticular Hinchey III/IV / Abbreviated laparotomy and negative pressure therapy for temporary closure of the abdomen as treatment of diverticular peritonitis Hinchey III/IV

Introducción: Los pacientes que se presentan con cuadros de peritonitis de origen diverticular (estadios Hinchey III o IV) en un contexto de sepsis severa con inestabilidad hemodinámica (shock séptico) la realización de anastomosis primaria presenta una alta tasa de dehiscencia anastomótica y mortalidad operatoria, aconsejándose la realización de una resección y abocamiento a la manera de Hartmann. Sin embargo, la alta tasa de complicaciones relacionadas a la confección del ostoma, la complejidad de la cirugía de restauración del tránsito intestinal, asociado a que entre el 40 % y el 60 % de los Hartmann no se reconstruyen, ha estimulado a que se intenten otras variables de resolución para esta compleja y grave patología. Diversas publicaciones en los últimos años han propuesto la táctica de "cirugía del control del daño" con el objeto de disminuir la morbimortalidad de estos gravísimos cuadros sépticos y a su vez reducir la tasa de ostomías. El objetivo de este trabajo es presentar nuestra experiencia inicial con esta modalidad de manejo de la peritonitis diverticular Hinchey III/IV sepsis severa e inestabilidad hemodinámica (shock séptico) y realizar una revisión bibliográfica del tema. Material y método: Estudio observacional, descriptivo, de series de casos. Entre noviembre de 2015 y diciembre de 2016. Servicio de coloproctología del complejo médico hospitalario Churruca-Visca de la ciudad de Buenos Aires y práctica privada de los autores. Se utilizó la técnica de laparotomía abreviada y cierre temporal del abdomen mediante un sistema de presión negativa. Resultados: En el periodo descripto se operaron 17 pacientes con peritonitis generalizada purulenta o fecal de origen diverticular. Catorce casos fueron Hinchey III (82,36%) y 3 casos Hinchey IV (17,64%). En 3 casos se observó inestabilidad hemodinámica en el preoperatorio o intraoperatorio. Todos ellos correspondientes al estadio IV de Hinchey. Se describen los 3 casos tratados mediante esta táctica quirúrgica. Discusión: La alta tasa de morbimortalidad de este subgrupo de pacientes incentivó a diversos grupos quirúrgicos a implementar la técnica de control del daño, permitiendo de esta manera estabilizar a los pacientes hemodinámicamente y en un segundo tiempo evaluar la reconstrucción del tránsito intestinal. En concordancia con estas publicaciones, dos de nuestros pacientes operados con esta estrategia, pudieron ser anastomosados luego del segundo lavado abdominal. Conclusión: En pacientes con peritonitis diverticular severa asociado a shock séptico el concepto de laparotomía abreviada con control inicial del foco séptico, cierre temporal del abdomen con sistema de presión negativa y posterior evaluación de la reconstrucción del tránsito intestinal, es muy alentador. Permitiendo una disminución de la morbimortalidad como así también del número de ostomías. (AU)

Introduction: Patients presenting with diverticular peritonitis (Hinchey III or IV stages) in a context of severe sepsis with hemodynamic instability (septic shock), performing primary anastomosis has a high rate of dehiscence anastomotic and operative mortality, advising the realization of a resection and ostoma in the manner of Hartmann. However, the high rate of complications related to performing of ostoma, the complexity of intestinal transit restoration surgery, associated with the 40% to 60% of Hartmann reversal not performed, has encouraged other variables to be attempted resolution for this complex and serious pathology. Several publications in recent years have proposed the tactic of "damage control surgery" in order to reduce the morbidity of these serious septic charts while reducing the rate of ostomies. The objective of this study is to present our initial experience with this modality of management of the diverticular peritonitis Hinchey III/IV severe sepsis and hemodynamic instability (septic shock) and to carry out a bibliographic review of the subject. Material and method: Observational, descriptive study of case series. Between November 2015 and December 2016. Coloproctology service of the Churruca-Visca hospital medical complex in the city of Buenos Aires and private practice of the authors. The technique of abbreviated laparotomy and temporary closure of the abdomen was used by a negative pressure system. Results: In the period described, 17 patients with generalized purulent or fecal peritonitis of diverticular origin were operated. Fourteen cases were Hinchey III (82.36%) and 3 cases Hinchey IV (17.64%).In 3 cases, hemodynamic instability was observed in the preoperative or intraoperative period. all of them corresponding to Hinchey's Stage IV. The 3 cases treated using this surgical tactic are described. Discussion: The high morbidity rate of this subgroup of patients encouraged various surgical groups to implement the damage control technique, thus allowing patients to stabilize hemodynamically and in a second time evaluate reconstruction intestinal transit. In line with these publications, two of our patients operated on with this strategy could be anastomosated after the second abdominal wash. Conclusion: In patients with severe diverticular peritonitis associated with septic shock, the concept of abbreviated laparotomy with initial control of the septic focus, temporary closure of the abdomen with negative pressure system and subsequent evaluation of transit reconstruction intestinal, it's encouraging. Allowing a decrease in morbidity as well as the number of ostomies. (AU)

Surgical treatment of tubal ectopic pregnancy through posterior colpotomy: experience from a Brazilian university hospital

The objective of this study was to evaluate the feasibility of posterior colpotomy for the surgical treatment of tubal ectopic pregnancy in hemodynamically stable women. We performed a retrospective analysis of medical records obtained over a period of 18 months. Twelve cases were identified, with the following characteristics: mean gestational age, 7.7 weeks; mean serum β-human chorionic gonadotropin level, 7,786 mIU/mL; and greater diameter of the mass, 15–69 mm. Treatment was successful in all cases. Salpingectomy was performed in 10 patients (83.3%) and salpingostomy, in 1 patient. The remaining patient only received peritoneal lavage, as the evidence of ectopic abortion with only a slightly dilated uterine tube was found during surgery. The mean surgical time was 42.5 minutes. In the analyzed cases, posterior colpotomy was found to be a feasible alternative method for the surgical treatment of tubal ectopic pregnancy in hemodynamically stable women.

Laparoscopia e lavado peritoneal no pré-operatório do adenocarcinoma gástrico: podemos modificar a conduta? / Preoperative laparoscopy and peritoneal lavage in gastric adenocarcinoma: can the approach be modified?

RESUMO Objetivo: avaliar se a laparoscopia com lavado peritoneal é superior à tomografia computadorizada para o estadiamento do adenocarcinoma gástrico e se pode modificar a conduta cirúrgica do paciente. Métodos: estudo retrospectivo de 46 pacientes portadores de adenocarcinoma gástrico tratados pela equipe de cirurgia digestiva do Hospital de Clínicas de Passo Fundo (RS), de janeiro de 2015 a dezembro de 2018, e submetidos à laparoscopia com lavado peritoneal pré-operatório. Todos os pacientes foram submetidos ao estadiamento clínico pré-operatório com tomografia computadorizada. Resultados: dos 46 pacientes analisados, a maioria apresentava tumores localizados na cárdia (34,8%), pouco diferenciados (69,6%) e do subtipo células em anel de sinete (65,2%). Em 91,3% deles a tomografia computadorizada não identificou carcinomatose peritoneal ou metástases à distância. Entre estes pacientes com tomografia computadorizada negativa para doença à distância, 21,8% apresentaram lavado peritoneal positivo para células neoplásicas e tiveram suas condutas terapêuticas modificadas. Conclusão: a laparoscopia e o lavado peritoneal alteraram a decisão cirúrgica em 21,8% dos pacientes, proporcionando um estadiamento pré-operatório mais fidedigno no adenocarcinoma gástrico.

ABSTRACT Objective: to assess whether laparoscopy with peritoneal lavage is superior to computed tomography for staging gastric adenocarcinoma and whether it can modify the surgical approach. Methods: we conducted a retrospective study of 46 patients with gastric adenocarcinoma treated by the digestive surgery team of the Passo Fundo Clinics Hospital (RS), from January 2015 to December 2018, and submitted to laparoscopy with preoperative peritoneal lavage. All patients underwent preoperative clinical staging with computed tomography. Results: of the 46 patients analyzed, the majority had tumors located in the cardia (34.8%), poorly differentiated (69.6%), and subtype signet ring cells (65.2%). In 91.3%, the computed tomography scan did not identify peritoneal carcinomatosis or distant metastasis. Among these patients with negative computed tomography for distant disease, 21.8% had positive peritoneal lavage for neoplastic cells and had their therapeutic approaches modified. Conclusion: laparoscopy and peritoneal lavage altered the surgical decision in 21.8% of patients, providing a more reliable preoperative staging in gastric adenocarcinoma.

Continuous peritoneal lavage with vacuum peritoneostomy: an experimental study

OBJECTIVE: Despite advances in diffuse peritonitis treatment protocols, some cases develop unfavorably. With the advent of vacuum therapy, the use of laparostomy to treat peritonitis has gained traction. Another treatment modality is continuous peritoneal lavage. However, maintaining this technique is difficult and has been associated with controversial results. We propose a new model of continuous peritoneal lavage that takes advantage of the features and benefits of vacuum laparostomy. METHOD: Pigs (Landrace and Large White) under general anesthesia were submitted to laparostomy through which a multiperforated tube was placed along each flank and exteriorized in the left and lower right quadrants. A vacuum dressing was applied, and intermittent negative pressure was maintained. Peritoneal dialysis solution (PDS) was then infused through the tubes for 36 hours. The stability of peritoneostomy with intermittent infusion of fluids, the system resistance to obstruction and leakage, water balance, hemodynamic and biochemical parameters were evaluated. Fluid disposition in the abdominal cavity was analyzed through CT. RESULTS: Even when negative pressure was not applied, the dressing maintained the integrity of the system, and there were no leaks or blockage of the catheters during the procedure. The aspirated volume by vacuum laparostomy was similar to the infused volume (9073.5±1496.35 mL versus 10165±235.73 mL, p=0.25), and there were no major changes in hemodynamic or biochemical analysis. According to CT images, 60 ml/kg PDS was sufficient to occupy all intra-abdominal spaces. CONCLUSION: Continuous peritoneal lavage with negative pressure proved to be technically possible and may be an option in the treatment of diffuse peritonitis.

CD4+CD69+ T cells and CD4+CD25+FoxP3+ Treg cells imbalance in peripheral blood, spleen and peritoneal lavage from pristane-induced systemic lupus erythematosus (SLE) mice

Abstract Background: Adaptive immune cells, including CD4+CD69+ and CD4+CD25+FoxP3+ regulatory T (Treg) cells, are important for maintaining immunological tolerance. In human systemic lupus erythematosus (SLE), CD4+CD25+FoxP3+ Treg cells are reduced, whereas CD69 expression is increased, resulting in a homeostatic immune imbalance that may intensify autoreactive T cell activity. To analyze the mechanisms implicated in autotolerance failure, we evaluated CD4+CD69+ and CD4+CD25+FoxP3+ T cells and interleukin profiles in a pristane-induced SLE experimental model. Methods: For lupus induction, 26 female Balb/c mice received a single intraperitoneal 0.5 ml dose of pristane, and 16 mice received the same dose of saline. Blood and spleen samples were collected from euthanized mice 90 and 120 days after pristane or saline inoculation. Mononuclear cells from peripheral blood (PBMC), peritoneal lavage (PL) and splenocytes were obtained by erythrocyte lysis and cryopreserved for further evaluation by flow cytometry using the GuavaEasyCyte TM HT. After thawing, cells were washed and stained with monoclonal antibodies against CD3, CD4, CD8, CD25, CD28, CD69, FoxP3, CD14 and Ly6C (BD Pharmingen TM). Interleukins were quantified using Multiplex® MAP. The Mann-Whitney test and the Pearson coefficient were used for statistical analysis, and p < 0.05 considered significant. Results: Compared with the controls, SLE-induced animals presented increased numbers of CD4+CD69+ T cells in the blood on T90 and T120 (p = 0.022 and p = 0.008) and in the spleen on T120 (p = 0.049), but there were decreased numbers in the PL (p = 0.049) on T120. The percentage of Treg was lower in blood (p < 0.005 and p < 0.012) on T90 and T120, in spleen (p = 0.043) on T120 and in PL (p = 0.001) on T90. Increased numbers of CD4+ CD69+ T cells in the PL were positively associated with high IL-2 (p = 0.486) and IFN-γ (p = 0.017) levels, whereas reduced Treg cells in the blood were negatively correlated with TNFα levels (p = 0.043) and positively correlated with TGFβ1 (p = 0.038). Conclusion: Increased numbers of CD4+CD69+ T cells and reduced numbers of CD4+CD25+FoxP3+ Treg cells with an altered interleukin profile suggests loss of autotolerance in pristane-induced lupus mice, which is similar to human lupus. Therefore, this model is useful in evaluating mechanisms of cellular activation, peripheral tolerance and homeostatic immune imbalance involved in human SLE.

Intraoperative radiofrequency ablation and distilled water peritoneal lavage for spontaneously ruptured hepatocellular carcinoma

PURPOSE: Spontaneously ruptured hepatocellular carcinoma (srHCC) is known to be a life-threatening complication with poor prognosis. Although there are various treatment modalities, there is no definite treatment guideline. The purpose of this study was to review the surgical outcome and prognosis of srHCC treated with intraoperative radiofrequency ablation (RFA) and distilled water peritoneal lavage (DWPL). METHODS: From March 2012 to October 2018, 9 patients with srHCC who underwent emergent surgery were reviewed. After hematoma removal, intraoperative RFA and DWPL were applied to all patients. Hepatectomy was performed if necessary. Patients with multiple tumors, distant metastasis, and vascular tumor involvement in radiologic imaging were excluded. RESULTS: Six of 9 patients with diameters less than 7 cm were able to obtain hemostasis using RFA alone (RFA group). However, 3 patients with a tumor size of more than 10 cm underwent liver resection because they could not obtain hemostasis with RFA (hepatectomy only group). The RFA group had shorter operation time (148.3 ± 31.7 minutes vs. 251.7 ± 20.2 minutes, P < 0.05) and less red blood cell transfusion (5.8 ± 2.5 packs vs. 24.0 ± 11.5 packs, P < 0.05) than the hepatectomy only group. There was no peritoneal metastasis at long-term follow-up in the RFA group. Five-year recurrence-free survival rate was 0% in both groups. However, 5-year overall survival rate was better in the RFA group (83.3% vs. 0%, P < 0.05). CONCLUSION: Intraoperative RFA and DWPL are easy to perform and theoretically the best methods for managing relatively small srHCC.

Apendicitis perforada, ¿lavar o no lavar la cavidad peritoneal? / Perforated appendicitis, peritoneal lavage versus non-lavage?

Introducción. El tratamiento adecuado de la cavidad peritoneal en la peritonitis secundaria constituye una preocupación permanente de los cirujanos y es primordial en el manejo integral del paciente. Objetivo. Evaluar los resultados de lavar la cavidad abdominal frente al secado peritoneal en los casos de peritonitis secundaria, por apendicitis aguda perforada. Material y métodos. Estudio observacional retrospectivo en el Servicio de Cirugía General del Hospital de Especialidades Carlos Andrade Marín, período enero 2016 a diciembre 2017. Se incluyeron 301 historias clínicas de pacientes con diagnóstico de apendicitis aguda perforada. El objetivo principal del estudio fue evaluar las complicaciones presentadas con cada uno de los procedimientos quirúrgicos empleados. Resultados. Los registros de 301 pacientes, 212 (70,4%) sometidos a lavado peritoneal y 89 (29,6%) a secado del peritoneo. La frecuencia de complicaciones entre los grupos estudiados fue similar, no hubo diferencias significativas. La única variable significativa fue el tiempo operatorio (OR 1,01, p<0,005). Conclusiones. No se encontraron diferencias significativas con el tipo de manejo de cavidad en pacientes con peritonitis secundaria a apendicitis aguda perforada (lavado versus secado de cavidad) en cuanto a complicaciones posoperatorias. El lavado peritoneal requirió un tiempo quirúrgico mayor al secado de la cavidad.

Introduction. The adequate treatment of the peritoneal cavity in peritonitis is a primary concern in the comprehensive management of the patient. Objective. To compare the results of thoroughly washing the peritoneal cavity vs simply just drying the peritoneal cavity in cases of secondary peritonitis due to acute perforated appendicitis. Materials and methods. A retrospective observational study was carried out in the General Surgery Department at Carlos Andrade Marín Specialties Hospital, from January 2016 until December 2017. The study main end-point was assessing the postoperative complication between peritoneal lavage versus cavity drying. Results. The records of 301 patients, 212 (70.4%) who underwent peritoneal lavage and 89 (29.6%) with just drying the peritoneum. The frequency of complications between both groups did not reach statistical significance. The only significant variable was the operative time (OR 1.01, p<0.005). Conclusions. No statistically significant differences were found with the type of cavity management in patients with peritonitis secondary to perforated appendicitis (lavage versus cavity drying). Peritoneal lavage required more time than cavity drying.

Xylitol Mitigate Neutrophil Inflammatory Response Against Porphyromonas gingivalis Infection

Periodontitis is generally a chronic disorder characterized by breakdown of tooth-supporting tissues, producing dentition loss. Porphyromonas gingivalis (P. gingivalis), a Gram-negative anaerobic rod, is one of the major pathogens associated with periodontitis. Neutrophils are first line defense cells in the oral cavity that play a significant role in inflammatory response. Xylitol is a known anti-caries agent and has anti-inflammatory effects. In this study, we conducted experiments to evaluate anti-inflammatory effects of xylitol on P. gingivalis infected neutrophils for possible usage in prevention and treatment of periodontal infections. P. gingivalis was intraperitoneally injected and peritoneal lavage was collected for cytokine determination. For in vitro study, neutrophils were collected from mouse peritoneal cells after zymosan injection or bone marrow cells. Neutrophils were stimulated with live P. gingivalis and ELISA was used to determine the effect of xylitol on P. gingivalis induced cytokine production. IL-1β, IL-6, TNF-α concentration and neutrophil population in the peritoneal lavage was increased in P. gingivalis-infected mouse. Peritoneal cells infected with live P. gingivalis revealed significantly increased production of IL-1β, IL-6 and TNF-α at multiplicity of infection of 10. Neutrophils from bone marrow and peritoneal lavage revealed increased production of IL-1β, IL-6 and TNF-α. Xylitol significantly mitigated P. gingivalis induced cytokine production in neutrophils. Findings indicate that xylitol is an anti-inflammatory agent in neutrophils infected with live P. gingivalis, that suggests its use in periodontitis management.

Large Cell Neuroendocrine Carcinoma of the Colon With Carcinomatosis Peritonei

Colorectal large-cell neuroendocrine carcinomas (NECs) are extremely rare and have very poor prognosis compared to adenocarcinomas. A 74-year-old man presented with abdominal pain, diarrhea and hematochezia. The histopathologic report of colonoscopic biopsy performed at a local clinic was a poorly differentiated carcinoma. An abdominopelvic computed scan revealed irregularly enhanced wall thickening at the sigmoid colon with regional fat stranding and lymphnode enlargement. He underwent a laparoscopic high anterior resection with selective peritonectomy for peritoneal carcinomatosis, intraoperative peritoneal irrigation chemotherapy, and early postoperative intraperitoneal chemotherapy for 5 days. The tumor had a high proliferation rate (mitotic count > 50/10 HPFs and 90% of the Ki-67 index) and lymph-node metastases had occurred. On immunohistochemistry, the tumor cells expressed CD56 and synaptophysin. Large-cell NEC was confirmed. Systemic chemotherapy with cisplatin/etoposide was done. The patient is still alive after 3 years with no evidence of recurrence.

Prognostic value of carcinoembryonic antigen levels in transoperative peritoneal lavage in patients with gastric cancer / Valor prognóstico dos níveis transoperatórios de antígeno carcinoembriônico em lavagem peritoneal de pacientes com câncer gástrico

ABSTRACT Background: The carcinoembryonic antigen level in peritoneal lavage has been showing to be a reliable prognostic factor in gastric cancer. Aim: To identify any association between carcinoembryonic antigen level in peritoneal lavage, in gastric cancer patients, with mortality, peritoneal recurrence, tumor relapse or other prognostic factors. Methods: In total, 30 patients (22 men, 8 women; median age 66 years) with resectable gastric cancer (mainly stage III and IV) were studied. Carcinoembryonic antigen level in peritoneal lavage was detected at operation by immunocytochemical method and a level over 210 ng/g of protein was considered as positive. Results: There were detected 10 positive cases (33.3%) of plCEA levels. These levels were associated with mortality, RR: 2.1 (p=0.018); peritoneal recurrence, OR: 9.0 (p=0.015); and relapse or gastric cancer progression, OR: 27.0 (p=0.001). Conclusion: Increased levels of plCEA fairly predicts mortality, peritoneal recurrence tumor relapse or cancer progression.

RESUMO Racional: Os níveis do antígeno carcinoembriônico no lavado peritoneal têm sido demonstrados como possível fator prognóstico de recidiva e mortalidade em pacientes com câncer gástrico. Objetivos: Medir seus níveis em lavado peritoneal durante operação de ressecção de câncer gástrico e ver se eles aumentados estão relacionados com mortalidade, recorrência, recidiva e outros fatores prognósticos. Métodos: Foi realizado lavado peritoneal durante ressecções de câncer gástrico; os níveis do antígeno carcinoembriônico nesse lavado maiores ou iguais a 210 ng/g foram considerados aumentados ou positivos. Resultados: Foram estudados 30 pacientes, destes, 33,33 % apresentaram níveis aumentados, os quais foram fator de risco para mortalidade em seis meses OR: 8,5 (1,458-49,539) IC 95%, mortalidade geral RR: 2,111 (1,314-3,391) IC 95%, mortalidade devido à doença OR: 12 (1,885-76,376) IC 95%, recorrência peritoneal OR: 9 (1,325-61,138) IC 95%, e recidiva ou progressão da doença OR: 27 (2,705-269,460) IC 95%. Conclusões: Os níveis aumentados do antígeno carcinoembriônico no lavado peritoneal foram fatores de risco para mortalidade, recorrência peritoneal, recidiva e progressão da doença em pacientes com câncer gástrico.

Animal model of continuous peritoneal lavage with vacuum peritoneostomy

Abstract Purpose: To establish and evaluate the feasibility of continuous peritoneal lavage with vacuum peritoneostomy in an animal model. Methods: Eight pigs aged 3-4 months, females, were anesthetized and submitted to laparotomy and installation of a continuous peritoneal lavage with vacuum peritoneostomy. The sta-bility of the system, the physiological effects of washing with NaCl 0.9% and the sys-tem clearance were evaluated. Results: Stability of vacuum peritoneostomy was observed, with no catheter leaks or obstructions and the clearance proved adequate, however, the mean volume of fluids aspirated by the peritoneostomy at the end of the experiment was higher than the volume infused by the catheters (p=0.02). Besides that, the animals presented a progressive increase in heart rate (p=0.04) and serum potassium (p=0.02). Conclusion: The continuous peritoneal lavage technique with vacuum peritoneostomy is feasible and presents adequate clearance.

The Detection of Messenger RNA for Carcinoembryonic Antigen and Cytokeratin 20 in Peritoneal Washing Fluid in Patients with Advanced Gastric Cancer / 대한소화기학회지

BACKGROUND/AIMS: Peritoneal micrometastasis is known to play an important role in the recurrence of gastric cancer. However, its effects remain equivocal. Herein, we examine the messenger RNA (mRNA) as tumor markers, carcinoembryonic antigen (CEA), and cytokeratin 20 (CK20), in peritoneal washing fluid. Moreover, we evaluate whether these results could predict the recurrence of gastric cancer following curative resection. METHODS: We prospectively enrolled 132 patients with gastric cancers, who had received an operation, between January 2010 and January 2013. The peritoneal lavage fluid was collected at the operation field and semi-quantitative PCR was performed using the primers for CEA and CK20. We excluded patients with stage IA (n=28) early gastric cancer, positive cytologic examination of peritoneal washings (n=7), and those who were lost during follow up (n=18). RESULTS: A total of 79 patients with gastric cancers were enrolled, and the mean follow-up period was 39.95±19.25 months (range, 5-72 months). According to the multivariate analysis, T4 stage at the initial diagnosis was significantly associated with recurrence. All cases of recurrence were CEA positive and 6 cases were CK20 positive. The positive and negative predictive values of CEA were 32.0% and 100%, respectively, whereas those of CK20 were 37.5% and 71.4%, respectively. Disease free survival of CK20-negative cases was 36.17±20.28 months and that of CK20-positive cases was 32.06±22.95 months (p=0.39). CONCLUSIONS: It is unlikely that the real time polymerase chain reaction results of mRNA for CEA and CK20 in peritoneal washing fluid can predict recurrence. However, negative results can convince surgeons to perform curative R0 resection.

Spontaneous Perforation of Pyometra

Pyometra is collection of purulent material which occurs when there is interference with its normal drainage. It is an uncommon condition with incidence of 0.1 to 0.5% of all gynecological patients. Spontaneous rupture of uterus is an extremely rare complication of pyometra. A 65-year-old lady presented with pain abdomen and purulent vaginal discharge. Preoperative diagnosis of pyometra was made by magnetic resonance imaging (MRI). Laparotomy followed by peritoneal lavage and repair of perforation was performed. Although spontaneously perforated pyometra is rare, the condition must be borne in mind with regard to elderly women with acute abdominal pain. Preoperative diagnosis of perforated pyometra is absolutely essential. Computed tomography (CT) and MRI are diagnostic tools. In selected cases conservative approach at surgery can be opted.

Efecto del secado frente al lavado peritoneal sobre la mortalidad y las complicaciones en la peritonitis secundaria / Effect of peritoneal cleaning versus peritoneal lavage upon mortality and complications in secondary peritonitis

Introducción. El control adecuado del foco infeccioso en la peritonitis es la piedra angular del tratamiento. Objetivo. Evaluar los resultados de la limpieza peritoneal comparada con el lavado peritoneal rutinario, en términos de complicaciones abdominales tempranas y muerte, en pacientes con peritonitis secundaria focal o difusa. Materiales y métodos. Se hizo un análisis retrospectivo de los pacientes con peritonitis que consultaron al Hospital Universitario San Vicente Fundación, entre 2009 y 2015, que cumplieran los criterios de inclusión y que fueron sometidos a cirugía para un control infeccioso inicial, con limpieza de la cavidad o con lavado peritoneal rutinario. Resultados. Se incluyeron 406 pacientes, 169 con limpieza peritoneal y 237 con lavado peritoneal. Se encontró que tener peritonitis en más de un cuadrante (odds ratio, OR=3,2; IC95% 1,74-5,79), líquido purulento o fecaloide (OR=3,7; IC 95% 1.80-7.73) y origen no apendicular (OR=2,41; IC95% 1,32-4,38), se asociaba con la práctica del lavado. Los factores relacionados con el desarrollo general de complicaciones fueron: ostomía (OR=3,25; IC95% 1,22-8,66), abdomen abierto (OR=7,0; IC95% 3,0-16,4) e ingreso a la unidad de cuidados intensivos (OR=3,93; IC95% 1,90-8,13). El lavado se asoció con el desarrollo de peritonitis residual (OR=4,83; IC95% 2,02-11,5) al compararlo con la limpieza peritoneal. Conclusiones. El manejo conservador de la peritonitis, controlando el foco infeccioso solo con limpieza, parece tener menos complicaciones (peritonitis residual, abdomen abierto, bacteriemia, necesidad de cuidados intensivos) y menor mortalidad que el lavado rutinario. Se requieren más estudios para validar dichos hallazgos.

Introduction: Control of infection in peritonitis is the cornerstone of treatment. The objective of this study was to evaluate the results of peritoneal cleaning compared to routine peritoneal lavage in terms of early abdominal complications and mortality in patients with focal or diffuse secondary peritonitis. Methods: We conducted a retrospective analysis of patients with peritonitis admitted to the Hospital Universitario San Vicente Fundación (Medellín, Colombia) in the period 2009 to 2015, which met the inclusion criteria and that were taken to surgery for initial infection control by cleaning or routine peritoneal lavage. Results: 406 patients were included, 169 underwent peritoneal cleaning and 237 peritoneal lavage. The finding of peritonitis in more than one quadrant (OR 3.2; 95% CI 1.74-5.79), liquid fecaloid/purulent (OR 3.7; 95% CI 1.80-7.73), and not of appendicular origin (OR 2.41; 95% CI 1.32-4.38) was associated with the election of peritoneal lavage. Factors related to the development of complications were, ostomy (OR 3.25 95% CI 1.22-8.66), open abdomen (OR 7.0; 95% CI 3.0-16.4), and admission to intensive care unit (OR 3.93 95% CI 1.90-8.13). Lavage is associated with the development of residual peritonitis (OR 4.83, 95% CI 2.02-11.5) when compared with the group of peritoneal cleaning. Conclusions: Conservative management of peritonitis controlling the infectious focus with only cleaning seems to have less complications (residual peritonitis, open abdomen, bacteremia, admission to ICU), and lower mortality than routine lavage. Further studies are needed to validate these findings.