Risk factors for postoperative sepsis in patients with gastrointestinal perforation

BACKGROUND Sepsis is fatal in patients with gastrointestinal perforation(GIP).However,few studies have focused on this issue.AIM To investigate the risk factors for postoperative sepsis in patients with GIP.METHODS This was a retrospective study performed at the Department of General Surgery in our treatment center.From January 2016 to December 2018,the medical records of patients with GIP who underwent emergency surgery were reviewed.Patients younger than 17 years or who did not undergo surgical treatment were excluded.The patients were divided into the postoperative sepsis group and the non-postoperative sepsis group.Clinical data for both groups were collected and compared,and the risk factors for postoperative sepsis were investigated.The institutional ethical committee of our hospital approved the study.RESULTS Two hundred twenty-six patients were admitted to our department with GIP.Fourteen patients were excluded:Four were under 17 years old,and 10 did not undergo emergency surgery due to high surgical risk and/or disagreement with the patients and their family members.Two hundred twelve patients were finally enrolled in the study;161 were men,and 51 were women.The average age was 62.98±15.65 years.Postoperative sepsis occurred in 48 cases.The prevalence of postoperative sepsis was 22.6%[95%confidence interval(CI):17.0%-28.3%].Twenty-eight patients(13.21%)died after emergency surgery.Multiple logistic regression analysis confirmed that the time interval from abdominal pain to emergency surgery[odds ratio(OR)=1.021,95%CI:1.005-1.038,P=0.006],colonic perforation(OR=2.761,CI:1.821–14.776,P=0.007),perforation diameter(OR=1.062,95%CI:1.007-1.121,P=0.027),and incidence of malignant tumorrelated perforation(OR=5.384,95%CI:1.762-32.844,P=0.021)were associated with postoperative sepsis.CONCLUSION The time interval from abdominal pain to surgery,colonic perforation,diameter of perforation,and the incidence of malignant tumor-related perforation were risk factors for postoperative sepsis in patients with GIP.

Diagnosis of upper gastrointestinal perforation complicated with fistula formation and subphrenic abscess by contrast-enhanced ultrasound:A case report

BACKGROUND Gastrointestinal perforation complicated by subphrenic abscess is a surgical emergency.Its diagnosis relies mainly on X-ray or computed tomography(CT),while the value of ultrasound,especially contrast-enhanced ultrasound(CEUS),has been underestimated.CASE SUMMARY A 37-year-old man presented with fever and edema of the lower extremities for 10 d.He had a history of laparoscopic repair of gastroduodenal perforation 6 mo prior.His first-time intravenous CEUS indicated a diagnosis of subphrenic abscess.He received antibiotic therapy and ultrasound-guided percutaneous drainage of the abscess.However,second-time intravenous CEUS revealed an unsatisfactory therapeutic effect.Intracavitary CEUS was proposed,and this examination detected communication between the abscess and the stomach.Upper gastrointestinal perforation complicated by fistula formation and subphrenic abscess was diagnosed with the help of CEUS.Abdominal CT and esophagogastroduodenoscopy confirmed the diagnosis.The patient recovered after the perforation was repaired by surgery.CONCLUSION Intravenous and intracavitary CEUS provides helpful information for the diagnosis of upper gastrointestinal perforation complicated by fistula formation and subphrenic abscess.

Endoscopic management of iatrogenic gastrointestinal perforations

Iatrogenic perforation(IP)is a rare but severe complication of endoscopy,and occurrences grow with the expansion of interventional endoscopy.Apart from symptoms and physical signs,CT scans provide an immediate and comprehensive diagnosis of IP and its severity.The general treatment is broad-spectrum antibiotics,intravenous nutrition,and close monitoring.Endoscopic treatments are considered as the first-line therapy.Endoclips are usually utilized for small perforations,while endoclips with endoloops and over the scope clip system are preferred for large ones.Covered self-expandable metal stents are effective for esophageal perforations.Fibrin glue and band ligation can be attempted,when the location of perforation is difficult for the clip placement.Close observation is required after the procedure.If endoscopic closure fails or deterioration occurs,surgical treatments should be requested.

In situ Injectable Tetra-PEG Hydrogel Bioadhesive for Sutureless Repair of Gastrointestinal Perforation

Hydrogel bioadhesives represent promising and efficient alternatives to sutures or staples for gastrointestinal(GI)perforation management.However,several concerns remain for the existing bioadhesives including slow and/or weak adhesive,poor mechanical strength,low biocompatibility,and poor biodegradability,which largely limit their clinical application in GI perforation repair.In this work,we introduce an in situ injectable Tetra-PEG hydrogel bioadhesive(SS)composed of tetra-armed poly(ethylene glycol)amine(Tetra-PEG-NH2)and tetra-armed poly(ethylene glycol)succinimidyl succinate(Tetra-PEG-SS)for the sutureless repair of GI defects.The SS hydrogel exhibits rapid gelation behavior and high burst pressure and is capable of providing instant robust adhesion and fluid-tight sealing in the ex vivo porcine intestinal and gastric models.Importantly,the succinyl ester linkers in the SS hydrogel endow the bioadhesive with suitable in vivo degradability to match the new GI tissue formation.The in vivo evaluation in the rat GI injured model further demonstrates the successful sutureless sealing and repair of the intestine and stomach by the SS hydrogel with the advantages of neglectable postsurgical adhesion,suppressed inflammation,and enhanced angiogenesis.Together,our results support potential clinical applications of the SS bioadhesive for the high-efficient repair of GI perforation.

Therapeutic effect of Western Medicine plus Traditional Chinese Medicine in the treatment of upper gastrointestinal tract perforation

OBJECTIVE: To explore the clinical efficacy of Traditional Chinese Medicine(TCM) combined with Western Medicine in the treatment of upper gastrointestinal tract perforation.METHODS: Totally 100 patients with upper gastrointestinal tract perforation hospitalized between January 2010 and January2015 were included and randomly divided into the control group and the observation group, 50 patients in each group. The patients in the control group received the conventional nonsurgical treatment of Western Medicine, whereas those in the observation group were treated by TCM plus the treatment given to the control group. The first period was defined as the closed perforation period, during which electro-acupuncture was performed at acupoints of Zusanli(ST36) and Zhongwan(Ren 12); the second period as the absorption period, during which Dachengqi Decoction was administered to restore normal bowel movement; the third period as the ulcer healing period,during which the TCM treatment was admini-stered based on the formula of Pingweisan. Patients in both groups were reexamined by endoscopy after 2 weeks of treatment.RESULTS: The time to relieve abdominal pain, the time to pass gas and the length of stay in the observation group were significantly improved compared with those in the control group(P<0.05). The cure rate of the observation group was significantly higher than that of the control group(P<0.05).After two weeks of treatment, in the observation group, the cured patients showed closed perforation, with disappearing mucosal congestion and edema, less white fur on the ulcers and shallower ulcers in the size of 3 to 5 mm; the ulcer was in the healing period and none of the patients showed acute perforation again. While in the control group, two patients were given endoscopy after 10 days of treatment, after which ulcer and acute perforation recurred.CONCLUSIONS: The treatment of upper gastrointestinal tract perforation by Western Medicine and TCM in combination could, at different stages, significantly shorten the time to relieve abdominal pain, the time to pass gas, and the length of stay, thus improving the cure rate.

Malignant atrophic papulosis:Two case reports

BACKGROUND Malignant atrophic papulosis is a rare and potentially lethal thrombo-occlusive microvasculopathy characterized by cutaneous papules and gastrointestinal perforation.The precise pathogenesis of this disease remains obscure.CASE SUMMARY We describe the case of a 67-year-old male patient who initially presented with cutaneous aubergine papules and dull pain in the epigastrium.One week after symptom onset,he was admitted to the hospital for worsening abdominal pain.Exploratory laparotomy showed patchy necrosis and subserosal white plaque lesions on the small intestinal wall,along with multiple perforations.Histological examination of the small intestine showed extensive hyperemia,edema,necrosis with varying degrees of inflammatory reactions in the small bowel wall,small vasculitis with fibrinoid necrosis and intraluminal thrombosis in the mesothelium.Based on the mentioned evidence,a diagnosis of malignant atrophic papulosis was made.We also present the case of a 46-year-old man with known cutaneous manifestations,abdominal pain,nausea and vomiting.His physical examination showed positive rebound tenderness.A computed tomography scan revealed free intraperitoneal air.He required surgical intervention on admission and then developed an esophageal perforation.He ultimately died of a massive hemorrhage.CONCLUSION In previously published cases of this disease,the cutaneous lesions initially appeared as small erythematous papules.Subsequently,the papules became porcelain-white atrophic depression lesions with a pink,telangiectatic peripheral rim.In one of the patients,the cutaneous lesions appeared as aubergine papules.The other patient developed multiple perforations in the gastrointestinal tract.Due to malignant atrophic papulosis affecting multiple organs,many authors speculated that it is not a specific entity.This case series serves as additional evidence for our hypothesis.