Department of General, Visceral, Thoracic and Transplant Surgery, University Hospital of Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.
Department of General, Visceral and Transplant Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
World J Emerg Surg. 2024 Jun 5;19(1):21. doi: 10.1186/s13017-024-00550-x.
The high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons' choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis.
Between January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis.
Length of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy.
A preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.
在继发性腹膜炎的急诊剖腹术中，高造口率是当前快速通道手术环境中需要改变的范例。尽管有越来越多的证据表明在腹膜炎环境中进行肠重建是可行的，但很少有数据证实外科医生在造口和吻合之间的选择。本回顾性分析的目的是确定预测在继发性腹膜炎的源头控制手术（SCS）中放置肠缝线的渗漏风险的术前和术中参数。
2014 年 1 月至 2020 年 12 月期间，有 497 例患者接受了 SCS 治疗继发性腹膜炎，其中 187 例接受了下消化道的原发性重建，而没有使用转流造口。在 47 例（25.1%）患者中，术后肠缝线的渗漏在revision 手术或通过计算机断层扫描直接确认。通过多变量分析检测到肠缝线结果的可量化预测因子。
与吻合完整的患者相比，SCS 后肠缝线渗漏的患者在 ICU 时间、住院死亡率和未能恢复到初始家庭环境方面明显更高（p<0.0001、p=0.0026 和 p=0.0009）。血清胆碱酯酶（sCHE）水平降低和腹膜炎广泛被确定为紧急剖腹术中放置肠缝线不足的独立危险因素。
术前 sCHE<4.5 kU/L 和广泛的粪便性腹膜炎与腹膜炎性腹部下消化道原发性重建后肠缝线不足的发生率显著增加相关。这些参数可以指导外科医生在紧急情况下选择最佳手术程序。
