Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Secondary peritonitis remains associated with high mortality and morbidity rates. Treatment of secondary peritonitis is still challenging even in the era of modern medicine. Surgical intervention for source control remains the cornerstone of treatment besides adequate antimicrobial therapy and when necessary intensive medical care measures and resuscitation. A randomized clinical trial showed that relaparotomy on demand (ROD) after initial emergency surgery was the preferred treatment strategy, irrespective of the severity and extent of peritonitis. ⋯ The effective and safe use of ROD requires intensive monitoring of the patient in a setting where diagnostic tests and decision making about relaparotomy are guaranteed round the clock. The lack of knowledge on timely and adequate patient selection, together with the lack of use of easy but reliable monitoring tools seem to hamper full implementation of ROD. The accuracy of the relaparotomy decision tool is reasonable for prediction of the formation of peritonitis and necessary selection of patients for computed tomography (CT). The value of CT in the early postoperative phase is unclear. Future research and innovative technologies should focus on the additive value of CT after surgical treatment for secondary peritonitis and on the further optimization of bedside prediction tools to enhance adequate patient selection for interventions in a multidisciplinary setting.
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Postoperative peritonitis is still a life-threatening complication after abdominal surgery and approximately 10,000 patients annually develop postoperative peritonitis in Germany. Early recognition and diagnosis before the onset of sepsis has remained a clinical challenge as no single specific screening test is available. ⋯ After diagnosis of diffuse postoperative peritonitis surgical revision is usually inevitable after intestinal interventions. Peritonitis after liver, biliary or pancreatic surgery is managed as a rule by means of differentiated therapy approaches depending on the severity.
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Despite intensive research efforts peritonitis leading to subsequent sepsis remains associated with a high mortality. The initial effector cells are the locally residing cells of the peritoneum, such as mesothelial cells, mast cells, macrophages and lymphocytes. Through the secretion of chemokines, an influx of neutrophils initially takes place followed by monocytes. ⋯ This is viewed as a concomitant derailing of inflammatory as well as anti-inflammatory responses, which leads to extensive apoptosis of lymphocytes. The presentation of apoptotic cells leads to a strong immunosuppression. Due to the coexistence of hyperinflammation and immunosuppression, exact knowledge of the current immune status of the patient is a prerequisite in the development of immunotherapies for the treatment of sepsis.
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Review Case Reports
[Streptococcal mediastinitis after thyroidectomy. A literature review].
Surgical site infections after thyroid surgery are mostly superficial and can be well treated. Streptococcal mediastinitis in contrast is a rare but life-threatening complication. ⋯ High fever and surgical site erythema in the early postoperative period after thyroid surgery can be signs of a GAS infection, which might lead to necrotizing, descending, life-threatening mediastinitis. Early diagnosis with support of computed tomography (CT) scans, immediate therapy including wound opening, lavage, intravenous antibiotic treatment with penicillin and clindamycin are vital. If treatment resistance occurs, cervical negative pressure treatment should be considered.
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Clinical forensic medicine does not only entail examination of patients after physical violence but also the option of clinical autopsies, e.g. after non-notifiable complications of medical interventions, after fatalities closely following medical interventions or fatalities as a result of injuries when the public prosecutor decides not to order a medicolegal autopsy. Based on this routine the Institute of Forensic Medicine at the University of Rostock offers a training course in topographical anatomy to physicians for further training in interventional and surgical disciplines. ⋯ Making autopsy rooms available for teaching and further training represents an additional feature to the profile of clinical forensic medicine. Lessons in topographical anatomy provide a great benefit for patient safety. It seems to be important to offer the opportunity to address individual interests in a closed meeting to consolidate skills and abilities in a non-judgemental environment. The post-mortem examiners have to ensure that the autopsy is carried out lege artis. Basic ethical principles and all regulations from an accredited scope have to be adhered to.