Current Utilization of Antifungal Agents for Intra-abdominal Infections Categorized by Patient Risk Factors During Surgical Procedures: A Literature Review.

The high morbidity and mortality rates associated with invasive fungal infections have led to the overutilization of empiric antifungal therapies. With increasing antibiotic resistance, the careful consideration of prophylactic or empiric antifungal use is critical. The purpose of this review is to evaluate the available literature regarding the current practice of utilizing antifungal agents for intra-abdominal infections based on specific surgical procedures and patient risk factors. Relevant articles were identified through a comprehensive literature search of several databases using the keywords antifungal agents, postoperative period, preoperative care, surgical procedures, and intra-abdominal infections. Only articles that evaluated the use of empiric antifungals for suspected or confirmed intra-abdominal infections and surgical procedures were included in this review. Based on the available literature, antifungal prophylaxis is appropriate in patients who meet the criteria for high-risk invasive candidiasis, kidney or liver transplant recipients, severely-immunocompromised patients with perforated peptic ulcer, peritonitis, and patients on peritoneal dialysis who are failing on a therapeutic antibiotic regimen. We acknowledge that the evidence for using antifungal therapy empirically for all surgical procedures is lacking, and the following review is based on available literature and current guidelines.

Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Mesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population. METHODS: The records of 702 consecutive patients undergoing primary laparoscopic Roux-en-Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO. During the last 9 months of the study, we offered elective laparoscopy to any patient who presented to us with symptoms of intermittent SBO. RESULTS: Of the 702 patients, 27 (3.8%) developed acute SBO. Of these 27 patients, 15 (55%) had obstruction related to an MIH. Nearly all patients had a typical history of intermittent abdominal pain, nausea, and bloating before developing acute SBO. Elective laparoscopy was offered to 11 patients with symptoms of intermittent SBO. Two patients who refused subsequently underwent operations for acute SBO. MIH was found at elective laparoscopic exploration in all cases. Of the 9 patients undergoing elective surgery, 3 (33%) had small bowel volvulus. CONCLUSION: SBO due to MIH after laparoscopic Roux-en-Y gastric bypass is typically preceded by symptoms of intermittent obstruction. Patients who have these herald symptoms should promptly be offered elective laparoscopic exploration. Elective repair of MIH can be performed safely and expeditiously.