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Injury Apr 2014Selective non-operative management (SNOM) of penetrating abdominal wounds has become increasingly common in the past two or three decades and is now accepted as routine... (Review)
Review
BACKGROUND
Selective non-operative management (SNOM) of penetrating abdominal wounds has become increasingly common in the past two or three decades and is now accepted as routine management for stab wounds. Gunshot wounds are more frequently managed with mandatory laparotomy but recently SNOM has been successfully applied. This review systematically appraises the evidence behind SNOM for civilian abdominal gunshot wounds.
METHODS
A Medline search from 1990 to present identified civilian studies examining success rates for SNOM of abdominal gunshot wounds. Case reports, editorials and abstracts were excluded. All other studies meeting the inclusion criteria of reporting the success rate of non-operative management of abdominal gunshot wounds were analysed.
RESULTS
Sixteen prospective and six retrospective studies met the inclusion criteria, including 18,602 patients with abdominal gunshot wounds. 32.2% (n=6072) of patients were initially managed non-operatively and 15.5% (n=943) required a delayed laparotomy. The presence of haemodynamic instability, peritonitis, GI bleeding or any co-existing pathology that prevented frequent serial examination of the abdomen from being performed were indications for immediate laparotomy in all studies. Delayed laparotomy results in similar outcomes to those in patients subjected to immediate laparotomy. Implementation of SNOM reduces the rates of negative and non-therapeutic laparotomies and reduces overall length of stay.
CONCLUSIONS
SNOM can be safely applied to some civilian patients with abdominal gunshot wounds and reduces the rates of negative or non-therapeutic laparotomy. Patients who require delayed laparotomy have similar rates of morbidity and mortality and similar length of stay to those patients who undergo immediate laparotomy.
Topics: Abdominal Injuries; Female; Gastrointestinal Hemorrhage; Humans; Laparotomy; Length of Stay; Male; Peritoneal Lavage; Peritonitis; Practice Guidelines as Topic; Time Factors; Tomography, X-Ray Computed; Wounds, Gunshot
PubMed: 23895795
DOI: 10.1016/j.injury.2013.07.008 -
The British Journal of Surgery Jun 2013Intraperitoneal cancer cells are detectable at the time of colorectal cancer resection in some patients. The significance of this, particularly in patients with no other... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Intraperitoneal cancer cells are detectable at the time of colorectal cancer resection in some patients. The significance of this, particularly in patients with no other adverse prognostic features, is poorly defined. Consequently peritoneal lavage is not part of routine practice during colorectal cancer resection, in contrast with other abdominal malignancies. The aim of this systematic review was to determine the effect of positive intraoperative peritoneal cytology on cancer-specific outcomes in colorectal cancer.
METHODS
A systematic review of key electronic journal databases was undertaken using the search terms 'peritoneal cytology' and 'colorectal' from 1980 to 2012. Studies including patients with frank peritoneal metastasis were excluded. Meta-analysis for overall survival, local/peritoneal recurrence and overall recurrence was performed.
RESULTS
Twelve cohort studies (2580 patients) met the inclusion criteria. The weighted mean yield was 11·6 (range 2·2-41) per cent. Yield rates were dependent on timing of sampling (before resection, 11·8 per cent; after resection, 13·2 per cent) and detection methods used (cytopathology, 8·4 per cent; immunocytochemistry, 28·3 per cent; polymerase chain reaction, 14·5 per cent). Meta-analysis showed that positive peritoneal lavage predicted worse overall survival (odds ratio (OR) 4·26, 95 per cent confidence interval 2·86 to 6·36; P < 0·001), local/peritoneal recurrence (OR 6·57, 2·30 to 18·79; P < 0·001) and overall recurrence (OR 4·02, 2·24 to 7·22; P < 0·001).
CONCLUSION
Evidence of intraoperative peritoneal tumour cells at colorectal cancer resection is predictive of adverse cancer outcomes.
Topics: Adult; Aged; Aged, 80 and over; Colorectal Neoplasms; Female; Humans; Intraoperative Care; Male; Middle Aged; Neoplasm Recurrence, Local; Neoplasm Staging; Peritoneal Lavage; Peritoneal Neoplasms; Survival Rate; Young Adult
PubMed: 23536330
DOI: 10.1002/bjs.9118 -
Surgical Oncology Jun 2013Free intraperitoneal tumour cells are an independent indicator of poor prognosis, and are encorporated in current staging systems in upper gastrointestinal cancers, but... (Review)
Review
BACKGROUND
Free intraperitoneal tumour cells are an independent indicator of poor prognosis, and are encorporated in current staging systems in upper gastrointestinal cancers, but not colorectal cancer. This systematic review aimed to evaluate the role and prognostic significance of positive peritoneal lavage in colorectal cancer.
METHODS
A search was undertaken of PUBMED/Medline and Cochrane databases for English language articles from 1990 to 2012 using a predefined search strategy. Both detection of free tumour cells and/or detection of tumour-associated antigens in peritoneal lavage fluid were considered a positive lavage. Primary endpoints were rates of positive lavage, recurrence and survival.
RESULTS
Of 3805 articles identified by title, 18 met inclusion criteria (n = 3197 patients, 59.5% colon, 40.5% rectal cancer). There was heterogeneity across studies in method of detection of peritoneal disease with 7 studies using more than one method (conventional cytology (14 studies), immunological techniques (6 studies), molecular techniques (4 studies)). The rate of positive lavage varied from 2.1% to 52% across studies, with a weighted mean rate of positive lavage of 13.17% overall (95% CI 12.74-13.59). In 10 studies (n = 2017) positive peritoneal lavage was associated with worse survival, and with increased recurrence in 12 (n = 2371). Clinicopathological factors frequently associated with positive lavage included macroscopic peritoneal disease, increasing tumour stage and nodal disease.
CONCLUSION
Positive peritoneal lavage is a negative prognostic factor in colorectal cancer. However, its utility in staging colorectal cancer is currently limited by wide variation in rates of positive lavage between studies due to differences in methods of peritoneal lavage fluid analysis.
Topics: Colorectal Neoplasms; Humans; Neoplasm Metastasis; Peritoneal Neoplasms; Prognosis
PubMed: 23481599
DOI: 10.1016/j.suronc.2013.01.001 -
Surgical Infections Apr 2013Over the past 20 years, there has been a global increase in the incidence and severity of group A streptococcal diseases. Primary group A streptococcal peritonitis is a... (Review)
Review
BACKGROUND
Over the past 20 years, there has been a global increase in the incidence and severity of group A streptococcal diseases. Primary group A streptococcal peritonitis is a life-threatening disease that may present in previously healthy individuals and progress to shock and severe organ dysfunction within a few hours. Our goal was to develop recommendations regarding the care of this group of patients.
METHODS
A systematic review of all adult cases of primary group A streptococcal peritonitis described in the English-language literature between January 1990 and December 2011.
RESULTS
Thirty-two patients with a median age at diagnosis of 38 years and a male:female ratio of 1:4 are described. Exploratory laparotomy was performed in 25 patients, 17 of whom had undergone abdominal computed tomography (CT). Laparoscopic peritoneal lavage was performed in five patients, and, in two patients, no operative interventions were undertaken.
CONCLUSION
The worrisome increase in invasive group A streptococcal disease means that presentations of primary group A streptococcal peritonitis are likely to become more common. The challenge for the treating surgeon is to consider the possibility of this diagnosis. In the current era of multi-detector CT technology, secondary peritonitis from an intra-abdominal source may be excluded reliably using abdominal CT. Exploratory laparotomy is not mandated, and paracentesis is sufficient to confirm the diagnosis and avoid operative morbidity in patients with localized intra-peritoneal fluid collections. Laparoscopic peritoneal lavage should be reserved for patients with widespread intra-peritoneal free fluid or whose condition deteriorates despite antibiotic therapy.
Topics: Adult; Aged, 80 and over; Female; Humans; Male; Middle Aged; Peritonitis; Streptococcal Infections; Streptococcus pyogenes
PubMed: 23464678
DOI: 10.1089/sur.2012.038 -
International Journal of Colorectal... Apr 2013This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This manuscript is a review of different surgical techniques to manage perforated colon diverticulitis.
OBJECTIVE
This study was conducted to compare the benefits and disadvantages of different surgical treatments for Hinchey III or IV type of colon diverticulitis.
METHODS
A systematic search was conducted in Medline, Embase, Cochrane Central Register of Controlled Trials, and the Science Citation Index (1990 and 2011). A total of 1,809 publications were identified and 14 studies with 1,041 patients were included in the study. Any surgical treatment was considered in this review. Mortality was considered the primary outcome, whereas hospital stay and reoperation rate were considered secondary outcomes.
RESULTS
Primary resection with anastomosis has a significant advantage in terms of lower mortality rate with respect to Hartmann's procedure (P = 0.02). The postoperative length of hospitalization was significantly shorter in the resection with anastomosis group (P < 0.001). Different findings have emerged from studies of patients with the primary resection with anastomosis vs laparoscopic peritoneal lavage and subsequent resection: overall surgical morbidity and hospital stay were lower in the laparoscopic peritoneal lavage group compared to the primary resection and anastomosis group (P < 0.001).
CONCLUSIONS
Despite numerous published articles on operative treatments for patients with generalized peritonitis from perforated diverticulitis, we found a marked heterogeneity between included studies limiting the possibility to summarize in a metanalytical method the data provided and make difficult to synthesize data in a quantitative fashion. The advantages in the group of colon resection with primary anastomosis in terms of lower mortality rate and postoperative stay should be interpreted with caution because of several limitations. Future randomized controlled trials are needed to further evaluate different surgical treatments for patients with generalized peritonitis from perforated diverticulitis.
Topics: Anastomosis, Surgical; Colon, Sigmoid; Colostomy; Diverticulitis, Colonic; Humans; Intestinal Perforation; Laparoscopy; Peritoneal Lavage; Suture Techniques
PubMed: 23242271
DOI: 10.1007/s00384-012-1622-4 -
Injury May 2011A recent Cochrane Review has demonstrated that emergency ultrasonography decreases the amount of computerised tomographic scans in blunt abdominal trauma.13 However,... (Review)
Review
STUDY OBJECTIVE
A recent Cochrane Review has demonstrated that emergency ultrasonography decreases the amount of computerised tomographic scans in blunt abdominal trauma.13 However, there is no systematic review that has evaluated the utility of the Focused Assessment with Sonography for Trauma(FAST) exam in penetrating torso trauma. We systematically reviewed the medical literature for the utility of the FAST exam to detect free intraperitoneal blood after penetrating torso trauma.
METHODS
We searched PUBMED and EMBASE databases for randomised controlled trials from 1965 through December 2009 using a search strategy derived from the following PICO formulation of our clinical question:
PATIENTS
patients (12+ years) sustaining penetrating trauma to the torso.
INTERVENTION
FAST exam during their initial trauma workup. Comparator: either local wound exploration (LWE),computerised tomography (CT), diagnostic peritoneal lavage (DPL), or laparotomy.
OUTCOME
intraperitoneal and pericardial free fluid. The methodological quality of the studies was assessed.Qualitative methods were used to summarise the study results.
ANALYSIS
Sensitivities and specificities were compared using a Forest Plot (95% CI) calculated by Revman 5 (Review Manager Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration,2008) between the FAST exam and definitive diagnostic modalities such as LWE, CT, DPL, or laporotomy.
RESULTS
We identified eight observational studies (n=565 patients) that met our selection criteria. The prevalence of a positive FAST exam after penetrating trauma was fairly low ranging from 24.2% to 56.3%.The FAST exam for penetrating trauma is a highly specific (94.1–100.0%), but not very sensitive (28.1–100%) diagnostic modality.
CONCLUSION
From the review of the literature, a positive FAST exam has a high incidence of intraabdominal injury and should prompt an exploratory laparotomy. However, a negative initial FAST exam after penetrating trauma should prompt further diagnostic studies such as LWE, CT, DPL, or laparotomy.
Topics: Abdominal Injuries; Critical Pathways; Hemoperitoneum; Humans; Male; Pericardial Effusion; Predictive Value of Tests; Randomized Controlled Trials as Topic; Thoracic Injuries; Tomography, X-Ray Computed; Ultrasonography; Wounds, Penetrating; Young Adult
PubMed: 20701908
DOI: 10.1016/j.injury.2010.07.249 -
World Journal of Surgery Sep 2010The use of peritoneal lavage in patients with acute pancreatitis remains controversial. While recent guidelines do not make a positive recommendation for its use, there... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The use of peritoneal lavage in patients with acute pancreatitis remains controversial. While recent guidelines do not make a positive recommendation for its use, there continues to be reports of clinical benefits from peritoneal lavage in this setting. The aim of this study was to systematically review the available randomized controlled trials of peritoneal lavage in patients with severe acute pancreatitis.
METHODS
The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and four major Chinese biomedical databases were searched. A random effects model was used in meta-analysis. The summary estimates were reported as risk ratios (RR) with corresponding 95% confidence interval.
RESULTS
Ten randomized controlled trials, encompassing a total of 469 patients, were included. When compared with conservative treatment, the use of peritoneal lavage did not result in a statistically significant difference in the risk of mortality (RR = 0.82; 95% CI 0.32-1.79; p = 0.69) and complications (RR = 1.33; 95% CI 0.99-2.12; p = 0.06). The use of peritoneal lavage with antiproteases, in comparison with peritoneal lavage only, also did not result in a statistically significant difference in the risk of mortality and complications.
CONCLUSION
The lavage of the peritoneal cavity in patients with severe acute pancreatitis does not appear to confer a clinical benefit. Whether lavage of the pancreatic bed after necrosectomy is beneficial has yet to be determined.
Topics: Acute Disease; Humans; Length of Stay; Pancreatitis; Peritoneal Lavage; Randomized Controlled Trials as Topic; Treatment Failure
PubMed: 20532765
DOI: 10.1007/s00268-010-0665-3 -
Colorectal Disease : the Official... Sep 2010This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis. (Review)
Review
AIM
This systematic review aimed to evaluate the efficacy, morbidity and mortality of laparoscopic peritoneal lavage for patients with perforated diverticulitis.
METHOD
We searched PubMed, EMBASE, Web of Science, the Cochrane Library and CINAHL databases, Google Scholar and five major publisher websites without language restriction. All articles which reported the use of laparoscopic peritoneal lavage for patients with perforated diverticulitis were included.
RESULTS
Two prospective cohort studies, nine retrospective case series and two case reports reporting 231 patients were selected for data extraction. Most (77%) patients had purulent peritonitis (Hinchey III). Laparoscopic peritoneal lavage successfully controlled abdominal and systemic sepsis in 95.7% of patients. Mortality was 1.7%, morbidity 10.4% and only four (1.7%) of the 231 patients received a colostomy.
CONCLUSION
There have been no publications of high methodological quality on laparoscopic peritoneal lavage for patients with perforated colonic diverticulitis. The published papers do, however, show promising results, with high efficacy, low mortality, low morbidity and a minimal need for a colostomy.
Topics: Diverticulitis, Colonic; Humans; Laparoscopy; Peritoneal Lavage; Peritonitis
PubMed: 19788490
DOI: 10.1111/j.1463-1318.2009.02052.x -
The Cochrane Database of Systematic... Jan 2008Peritonitis is a common complication of peritoneal dialysis (PD) and is associated with significant morbidity. Adequate treatment is essential to reduce morbidity and... (Review)
Review
BACKGROUND
Peritonitis is a common complication of peritoneal dialysis (PD) and is associated with significant morbidity. Adequate treatment is essential to reduce morbidity and recurrence.
OBJECTIVES
To evaluate the benefits and harms of treatments for PD-associated peritonitis.
SEARCH STRATEGY
We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE, EMBASE and reference lists without language restriction. Date of search: February 2005
SELECTION CRITERIA
All randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in peritoneal dialysis patients (adults and children) evaluating: administration of an antibiotic(s) by different routes (e.g. oral, intraperitoneal, intravenous); dose of an antibiotic agent(s); different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal were included.
DATA COLLECTION AND ANALYSIS
Two authors extracted data on study quality and outcomes. Statistical analyses were performed using the random effects model and the dichotomous results were expressed as relative risk (RR) with 95% confidence intervals (CI) and continuous outcomes as mean difference (WMD) with 95% CI.
MAIN RESULTS
We identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglobulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). For relapsing or persistent peritonitis, simultaneous catheter removal/replacement was superior to urokinase at reducing treatment failure rates (1 study, 37 patients: RR 2.35, 95% CI 1.13 to 4.91). Continuous IP and intermittent IP antibiotic dosing had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure (1 study, 75 patients: RR 3.52, 95% CI 1.26 to 9.81). The methodological quality of most included studies was suboptimal and outcome definitions were often inconsistent. There were no RCTs regarding duration of antibiotics or timing of catheter removal.
AUTHORS' CONCLUSIONS
Based on one study, IP administration of antibiotics is superior to IV dosing for treating PD peritonitis. Intermittent and continuous dosing of antibiotics are equally efficacious. There is no role shown for routine peritoneal lavage or use of urokinase. No interventions were found to be associated with significant harm.
Topics: Administration, Oral; Anti-Bacterial Agents; Fibrinolytic Agents; Humans; Immunoglobulins; Infusions, Parenteral; Injections, Intravenous; Peritoneal Dialysis; Peritoneal Lavage; Peritonitis; Randomized Controlled Trials as Topic; Urokinase-Type Plasminogen Activator
PubMed: 18254075
DOI: 10.1002/14651858.CD005284.pub2 -
American Journal of Kidney Diseases :... Dec 2007Peritonitis frequently complicates peritoneal dialysis. Appropriate treatment is essential to reduce adverse outcomes. Available trial evidence about peritoneal dialysis... (Review)
Review
BACKGROUND
Peritonitis frequently complicates peritoneal dialysis. Appropriate treatment is essential to reduce adverse outcomes. Available trial evidence about peritoneal dialysis peritonitis treatment was evaluated.
SELECTION CRITERIA FOR STUDIES
The Cochrane CENTRAL Registry (2005 issue), MEDLINE (1966 to February 2006), EMBASE (1985 to February 2006), and reference lists were searched to identify randomized trials of treatments for patients with peritoneal dialysis peritonitis.
INTERVENTIONS
Trials of antibiotics (comparisons of routes, agents, and dosing regimens), fibrinolytic agents, peritoneal lavage, and intraperitoneal immunoglobulin.
OUTCOMES
Treatment failure, relapse, catheter removal, microbiological eradication, hospitalization, all-cause mortality, and adverse reactions.
RESULTS
36 eligible trials were identified: 30 trials (1,800 patients) of antibiotics; 4 trials (229 patients) of urokinase; 1 trial of peritoneal lavage (36 patients); and 1 trial of intraperitoneal immunoglobulin (24 patients). No superior antimicrobial class was identified. In particular, glycopeptides and first-generation cephalosporins were equivalent (3 trials, 387 patients; relative risk [RR], 1.84; 95% confidence interval [CI], 0.95 to 3.58). Simultaneous catheter removal/replacement was superior to urokinase at decreasing treatment failures (1 trial, 37 patients; RR, 2.35; 95% CI, 1.13 to 4.91). Continuous and intermittent intraperitoneal antibiotic dosing were equivalent regarding treatment failure (4 trials, 338 patients; RR, 0.69; 95% CI, 0.37 to 1.30) and relapse (4 trials, 324 patients; RR, 0.93; 95% CI, 0.63 to 1.39). One trial showed superiority of intraperitoneal antibiotics over intravenous therapy.
LIMITATIONS
The method quality of trials generally was suboptimal and outcome definitions were inconsistent. Small patient numbers led to inadequate power to show an effect. Interventions, such as optimal duration of antibiotic therapy, were not evaluated.
CONCLUSIONS
Trials did not identify superior antibiotic regimens. Intermittent and continuous antibiotic dosing are equivalent treatment strategies.
Topics: Anti-Bacterial Agents; Fibrinolytic Agents; Humans; Peritoneal Dialysis; Peritoneal Lavage; Peritonitis; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 18037098
DOI: 10.1053/j.ajkd.2007.08.015