Comparison of Operative Outcomes Between Monopolar and Bipolar Coagulation in Hepatectomy: A Propensity Score-Matched Analysis in a Single Center

Background: Various hemostatic devices have been utilized to reduce blood loss during hepatectomy. Nonetheless, a comparison between monopolar and bipolar coagulation, particularly their usefulness or inferiority, has been poorly documented. The aim of this study is to reveal the characteristics of these hemostatic devices.Methods: A total of 264 patients who underwent open hepatectomy at our institution from January 2009 to December 2018 were included. Monopolar and bipolar hemostatic devices were used in 160 (monopolar group) and 104 (bipolar group) cases, respectively. Operative outcomes and thermal damage to the resected specimens were compared between these groups using propensity score matching according to background factors. Multivariate logistic regression analysis was performed to identify predictive factors for postoperative complications.Results: After propensity score matching, 73 patients per group were enrolled. The monopolar group had significantly lower total operative time (239 vs. 275 min; P=0.013) and intraoperative blood loss (487 vs. 790 mL; P<0.001). However, the incidence rates of ascites (27.4% vs. 8.2%; P=0.002) and grade ≥3 intra-abdominal infection (12.3% vs. 2.7%; P=0.028) were significantly higher in the monopolar group. Thermal damage to the resected specimens was significantly longer in the monopolar group (4.6 vs. 1.2 mm; P<0.001). Use of monopolar hemostatic device was an independent risk factor for ascites (odds ratio, 5.626, 95% confidence interval 1.881–16.827; P=0.002) and severe intra-abdominal infection (odds ratio, 5.905, 95% confidence interval 1.096–31.825; P=0.039).Conclusions: Although monopolar devices have an excellent hemostatic ability, they might damage the remnant liver. The use of monopolar devices can be one of the factors that increase the frequency of complications.

Efficacy of Combined Therapy with Nitroimidazole Drugs and Broad-Spectrum Antibiotics on Intra-Abdominal Infection: A 10 Years Real-World Cohort Study

Background: Abdominal infection still has a high mortality rate, and whether the combination of nitroimidazoles against obligate anaerobe could improve the outcome of abdominal infection remains controversial. Objective: This study aimed at exploring the clinical efficacy of broad-spectrum antibiotics combined with nitroimidazoles in the treatment of abdominal infection. Methods: Clinical data of patients with abdominal infection who received broad-spectrum antibiotics alone (BSA) or broad-spectrum antibiotics in combination with nitroimidazole (NCBSA) at a single center from June 2010 to May 2020 were retrospectively reviewed. One-to-one propensity score matching (PSM) was performed to adjust the potential differences in age, gender, APACHE II score and SOFA score of the two groups. Clinical effective rate, hospitalization days and total hospitalization costs were compared between the two groups. Meanwhile, subgroup efficacy was analyzed according to disease severity (APACH II score) and whether abdominal surgery was performed. Result: A total of 149 propensity score-matched case pairs were included in this study. There was no statistical difference in clinical effective rates between the two groups (P = 0.236). The patients in BSA group had shorter hospital stays (18d vs 27d, P = 0.001) and lower hospitalization costs (85185.7 yuan vs 187898.3 yuan, P < 0.001). However, the body temperature and PCT in patients in NCBSA group were higher than those in BSA group (P = 0.007 and P = 0.045, respectively), and CRP and WBC values in NCBSA group also were higher, but there were no significant differences between the two groups (P = 0.105 and P = 0.170, respectively). And more patients (92 vs 38) in NCBSA group underwent abdominal surgery, which indicated the infection and clinical conditons in NCBSA group were probably more severe. Subgroup analysis showed that the severity of the disease and whether the patient suffered postoperative co-infection did not affect the therapeutic effect of the two groups (P > 0.05). Conclusion: The clinical efficacy of broad-spectrum antibiotics combined with nitroimidazoles for abdominal infection was similar to that of broad-spectrum antibiotics alone, and whether the combination of nitroimidazoles in these conditions still needs more lcinical evidence.

Efficacy of Combined Therapy With Nitroimidazole Drugs and Broad-spectrum Antibiotics on Intra-abdominal Infection: a 10 Years Real-world Cohort Study

Background: Abdominal infection still has a high mortality rate, and whether the combination of nitroimidazoles against obligate anaerobe could improve the outcome of abdominal infection remains controversial. Objective: This study aimed at exploring the clinical efficacy of broad-spectrum antibiotics combined with nitroimidazoles in the treatment of abdominal infection. Methods: Clinical data of patients with abdominal infection who received broad-spectrum antibiotics alone (BSA) or broad-spectrum antibiotics in combination with nitroimidazole (NCBSA) at a single center from June 2010 to May 2020 were retrospectively reviewed. One-to-one propensity score matching (PSM) was performed to adjust the potential differences in age, gender, APACHE II score and SOFA score of the two groups. Clinical effective rate, hospitalization days and total hospitalization costs were compared between the two groups. Meanwhile, subgroup efficacy was analyzed according to disease severity (APACH II score) and whether abdominal surgery was performed. Result: A total of 149 propensity score-matched case pairs were included in this study. There was no statistical difference in clinical effective rates between the two groups (P = 0.236). The patients in BSA group had shorter hospital stays (18d vs 27d, P = 0.001) and lower hospitalization costs (85185.7 yuan vs 187898.3 yuan, P < 0.001). However, the body temperature and PCT in patients in NCBSA group were higher than those in BSA group (P = 0.007 and P = 0.045, respectively), and CRP and WBC values in NCBSA group also were higher, but there were no significant differences between the two groups (P = 0.105 and P = 0.170, respectively). And more patients (92 vs 38) in NCBSA group underwent abdominal surgery, which indicated the infection and clinical conditons in NCBSA group were probably more severe. Subgroup analysis showed that the severity of the disease and whether the patient suffered postoperative co-infection did not affect the therapeutic effect of the two groups (P > 0.05). Conclusion: The clinical efficacy of broad-spectrum antibiotics combined with nitroimidazoles for abdominal infection was similar to that of broad-spectrum antibiotics alone, and whether the combination of nitroimidazoles in these conditions still needs more lcinical evidence.

Analysis of six tonB gene homologs in Bacteroides fragilis revealed that tonB3 is essential for survival in experimental intestinal colonization and intra-abdominal infection

The opportunistic, anaerobic pathogen and commensal of the human large intestinal tract, Bacteroides fragilis strain 638R, contains six predicted TonB proteins, termed TonB1-6, four ExbBs orthologs, ExbB1-4, and five ExbDs orthologs, ExbD1-5. The inner membrane TonB/ExbB/ExbD complex harvests energy from the proton motive force (Δp) and the TonB C-terminal domain interacts with and transduces energy to outer membrane TonB-dependent transporters (TBDTs). However, TonB’s role in activating nearly one hundred TBDTs for nutrient acquisition in B. fragilis during intestinal colonization and extraintestinal infection has not been established. In this study, we show that growth was abolished in the ΔtonB3 mutant when heme, vitamin B12, Fe(III)-ferrichrome, starch, mucin-glycans, or N-linked glycans were used as a substrate for growth in vitro . Genetic complementation of the ΔtonB3 mutant with the tonB3 gene restored growth on these substrates. The ΔtonB1 , ΔtonB2 , ΔtonB4, ΔtonB5, and ΔtonB6 single mutants did not show a growth defect. This indicates that there was no functional compensation for the lack of TonB3, and it demonstrates that TonB3, alone, drives the TBDTs involved in the transport of essential nutrients. The ΔtonB3 mutant had a severe growth defect in a mouse model of intestinal colonization compared to the parent strain. This intestinal growth defect was enhanced in the ΔtonB3 ΔtonB6 double mutant strain which completely lost its ability to colonize the mouse intestinal tract compared to the parent strain. The ΔtonB1 , ΔtonB2 , ΔtonB4, and ΔtonB5 mutants did not significantly affect intestinal colonization. Moreover, the survival of the ΔtonB3 mutant strain was completely eradicated in a rat model of intra-abdominal infection. Taken together, these findings show that TonB3 was essential for survival in vivo . The genetic organization of tonB1 , tonB2 , tonB4, tonB5, and tonB6 gene orthologs indicates that they may interact with periplasmic and nonreceptor outer membrane proteins, but the physiological relevance of this has not been defined. Because anaerobic fermentation metabolism yields a lower Δp than aerobic respiration and B. fragilis has a reduced redox state in its periplasmic space - in contrast to an oxidative environment in aerobes - it remains to be determined if the diverse system of TonB/ExbB/ExbD orthologs encoded by B. fragilis have an increased sensitivity to PMF (relative to aerobic bacteria) to allow for the harvesting of energy under anaerobic conditions.

Predictors of relaparotomy for persisting intra abdominal infection in secondary peritonitis

Background: Peritonitis is one of the commonest causes of acute abdomen in Ethiopia. One of the causes of high morbidity and mortality is persistent intraabdominal infection. The two essential approaches for managing post-op collection are laparotomy on-demand and planned Relaparotomy. Despite multiple studies, both have comparative mortality. This study aimed to identify clinical variables that are predictive of persistent intraabdominal infection. Methods: A retrospective study was conducted on patients who were operated on from Sept 2018 to April 2020 at two affiliated referral hospitals of AAU, college of Medicine; Yekatit 12 hospital Medical College and Minilik II referral Hospital. All of the patients were cases of secondary peritonitis. Clinical progress of the patients from admission to discharge/death was documented. Multiple preoperative and intraoperative variables were analyzed to develop the predictive clinical model. Results: Out of 172 laparotomy cases for secondary peritonitis, 40 (23.3%) required relaparotomy for postop collection. From Patients who developed postop collection, 45% of them were diagnosed after pus/Gi content leaked through the surgical wound. The mortality rate of patients who develop postop collection and undergone relaparotomy was 27.5 % and 4.5% for those without postop collection. Logistic regression identified 4 variables as having significant predictive value: Duration of illness more than 5 days, Systolic BP 1000 ml, and small bowel as a source of contamination. Overall prediction successes of the above model is 88.4% (sensitivity 53.3%, specificity 96.8%). Conclusion: Management of persistent intra-abdominal infection is challenging. We have identified 4 clinical variables that predict persistent intraabdominal infection requiring relaparotomy. These sets of variables can be a milestone for future validation study before being inserted in today to day clinical practice.

413 The Clinical Efficacy of Intra-Operative Peritoneal Fluid Sampling in Abdominal infections

Aim To uncover the practical efficacy of intra-operative peritoneal fluid sampling and the impact on antibiotic prescription and clinical outcomes in patients undergoing emergency surgery due to intra-abdominal infections. Method Our retrospective study included all patients undergoing emergency surgery for intra-abdominal infections at Southend University Hospital over 6 months (January – July 2019). Data was collected from electronic patient records, case notes and microbiology reports and included the following information: patient age demographics; type of infection; peritoneal fluid sampling indication; samples taken; details of swab culture report including organisms grown and antibiotic sensitivity; clinical course and incidence of subsequent intra-abdominal infection to include readmission and/or further procedures; the type, duration and route of antibiotic prescribed and duration of hospital stay. This audit was approved by the Departmental Audit Lead. Results 441 patients undergoing emergency surgery for intra-abdominal infection were identified. After exclusions, intra-operative peritoneal fluid samples were indicated in 77 patients (mean age 39.4 years). Of these only 3 had samples taken (3.9%). The most common organisms isolated were mixed anaerobes followed by Streptococcus angiosus. The most common antibiotic sensitivity was Metronidazole and Penicillin. One readmission occurred due to an intra-abdominal tubo-ovarian abscess. Conclusions The study shows that the current practice in our hospital regarding intra-operative peritoneal fluid sampling in intra-abdominal infections reflects the present widely held attitudes regarding its reduced practical utility. Abandoning routine sampling had no significant impact on the clinical course and may be more cost-effective. The study may help surgeons reflect on changing perspectives on this traditional practice.

Initial antimicrobial management of sepsis

Sepsis is a common consequence of infection, associated with a mortality rate > 25%. Although community-acquired sepsis is more common, hospital-acquired infection is more lethal. The most common site of infection is the lung, followed by abdominal infection, catheter-associated blood steam infection and urinary tract infection. Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens. To reduce mortality, it is necessary to give immediate, empiric, broad-spectrum therapy to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship. Biomarkers such a procalcitonin can provide decision support for antibiotic use, and may identify patients with a low likelihood of infection, and in some settings, can guide duration of antibiotic therapy. Sepsis can involve drug-resistant pathogens, and this often necessitates consideration of newer antimicrobial agents.