EP.FRI.8 Hajibandeh index predicts nature of peritoneal contamination and risk of postoperative mortality in patients with acute abdominal pathology: A multicentre cohort study

Aims To develop and validate intraperitoneal contamination index, Hajibandeh Index (HI), derived from combined levels of CRP, lactate, neutrophils, lymphocytes and albumin in predicting the nature of peritoneal contamination and risk of postoperative mortality in patients with acute abdominal pathology. Methods A multicentre cohort study was conducted to develop and validate an index to predict presence of purulent and feculent contamination and risk of postoperative mortality in patients with acute abdominal pathology. All adult patients with acute abdominal pathology requiring emergency laparotomy between 2014 and 2020 were included. The index was developed in a primary cohort and was validated in retrospective and prospective validation cohorts. ROC curve analysis was performed to determine discrimination of the index and cut-off values of HI that could predict nature of peritoneal contamination and postoperative mortality. Results 737 patients were included (234 in primary cohort, 234 in retrospective validation cohort, and 269 in prospective validation cohort). The analyses identified HI of 24.76 as cut-off value for purulent contamination (AUC:0.78,P<0.0001;sensitivity:82.4%,specificity:60.9%); HI of 33.84 as cut-off value for feculent contamination (AUC:0.78, P<0.0001;sensitivity:82%,specificity:67.8%), and HI of 33.47 as cut-off value for postoperative mortality (AUC:0.70,P<0.0001;sensitivity:72.7%, specificity:58.47%). The results of the primary cohort and validation cohorts were comparable. Conclusions HI predicts presence of purulent and feculent contamination in patients with acute abdominal pathology and risk of postoperative mortality in patients undergoing emergency laparotomy. Future studies should investigate the effect of HI on accuracy of preoperative prognostic scoring tools and on patient selection for operative or non-operative management of underlying abdominal pathology.

TP9.2.10The risk and predictors of mortality in octogenarians undergoing emergency laparotomy: A multicentre cohort study

Aims To evaluate the risk and predictors of postoperative mortality in octogenarians undergoing emergency laparotomy. Methods In compliance with STROCSS guideline for observational studies, we conducted a multicentre retrospective cohort study. All consecutive patients aged over 80 with acute abdominal pathology requiring emergency laparotomy between April 2014 and August 2019 were considered eligible for inclusion. The primary outcome measure was 30-day postoperative mortality and the secondary outcome measures were in-hospital mortality and 1-year mortality. Statistical analyses included simple descriptive statistics, binary logistic regression analyses, and Kaplan–Meier survival statistics. Results A total of 523 octogenarians were eligible for inclusion. Emergency laparotomy in octogenarians was associated with 21.8% (95% CI 18.3-25.6%) 30-day postoperative mortality, 22.6% (95% CI 19.0-26.4%) in-hospital mortality, and 40.2% (95% CI 35.9-44.5%) 1-year mortality. Binary logistic regression analysis identified ASA status (OR: 2.49,95% CI 1.82-3.38,P<0.0001) and peritoneal contamination (OR: 2.00, 95% CI 1.30-3.08, P = 0.002) as predictors of 30-day postoperative mortality. The ASA status (OR: 1.92,95% CI 1.50-2.46,P<0.0001), peritoneal contamination (OR: 1.57,95% CI 1.07-2.48,P=0.020) and presence of malignancy (OR: 2.06,95% CI 1.36-3.10,P=0.001) were predictors of 1-year mortality. Log-rank test showed significant difference in postoperative survival rates among patients with different ASA status (P < 0.0001) and between patients with and without peritoneal contamination (P = 0.0011). Conclusions Emergency laparotomies in patients older than 80 years with ASA status more than 3 in the presence of peritoneal contamination carries a high risk of immediate postoperative and 1-year mortality. There is a need to incorporate modern prognosticators into the available preoperative mortality risk assessment tools.

Predicting peritoneal contamination with enterobacteria producing extended-spectrum beta-lactamases and choosing empirical antibacterial therapy for postoperative peritonitis in cancer patients

Relevance: Enterobacteriaceae family microorganisms, specifically E. coli and K. pneumoniae isolates, are the most common activators of postoperative peritonitis in oncology. Many of these microorganisms produce extended-spectrum beta-lactamases (ESBL). The deemed resistance of ESBL-producing enterobacteria to all β-lactam antibiotics, except for carbapenems, leads to the ineffectiveness of empiric antibiotic therapy. The purpose of the study was to define the risk factors of peritoneal contamination with ESBL-producing enterobacteria for choosing optimal empirical antibacterial therapy on the example of a specific cancer patient with postoperative peritonitis. Results: Independent risk factors of peritoneal contamination with ESBL-producing enterobacteria included “the administration of antibiotics for more than three days” (OR 106, 95% CI 21.0-537, p<0.001), “two or more repeated laparotomies” (OR 2.66, 95% CI 1.32-5.34, p=0.006), and “postoperative preventive antibiotic treatment” (OR 0.17, 95% CI 0.04-0.75, p=0.02). The obtained prognostic model allowed predicting the infection with ESBL-producing enterobacteria before establishing the postoperative peritonitis microbial etiology. The model sensitivity was 94.7%, overall predictive accuracy was 73.1. Conclusion: Prolonged administration of antibiotics (3rd-generation cephalosporins and/or fluoroquinolones) after cancer surgery to prevent surgical infections is the main independent risk factor of peritoneal contamination with ESBL- producing enterobacteria.

Predicting peritoneal contamination with enterobacteria producing extendedspectrum beta-lactamases and choosing empirical antibacterial therapy for postoperative peritonitis in cancer patients

Enterobacteriaceae family microorganisms, specifically E. coli and K. pneumoniae isolates, are the most common activators of postoperative peritonitis in oncology. Many of these microorganisms produce extended-spectrum beta-lactamases (ESBL). The deemed resistance of ESBL-producing enterobacteria to all β-lactam antibiotics, except for carbapenems, leads to ineffectiveness of empiric antibiotic therapy. Purpose of the study: To define the risk factors of peritoneal contamination with ESBL-producing enterobacteria for choosing optimal empirical antibacterial therapy on the example of a specific cancer patient with postoperative peritonitis. Results: Independent risk factors of peritoneal contamination with ESBL-producing enterobacteria included “the administration of antibiotics for more than three days” (OR 106, 95% CI 21.0-537, p<0.001), “two or more relaparotomies” (OR 2.66, 95% CI 1.32-5.34, p =0.006), and “postoperative preventive antibiotic treatment” (OR 0.17, 95% CI 0.04-0.75, p =0.02). The obtained prognostic model allowed predicting the infection with ESBL-producing enterobacteria before establishing the postoperative peritonitis microbial etiology. The model sensitivity was 94.7%, overall predictive accuracy was 73.1. Conclusion: Prolonged administration of antibiotics (3rd-generation cephalosporins and/or fluoroquinolones) after cancer surgery to prevent surgical infections is the main independent risk factor of peritoneal contamination with ESBL- producing enterobacteria.

Risk Factors for Anastomotic Leakage in Patients with Rectal Tumors Undergoing Anterior Resection within an ERAS Protocol: Results from the Swedish ERAS Database

Background Research on risk factors for anastomotic leakage (AL) alone within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL and study short-term outcome after AL in patients operated with anterior resection (AR). Methods All prospectively and consecutively recorded patients operated with AR in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between January 2010 and February 2020 were included. The cohort was evaluated regarding risk factors for AL and short-term outcomes, including uni- and multivariate analysis. Pre-, intra- and postoperative compliance to ERAS®Society guidelines was calculated and evaluated. Results Altogether 1900 patients were included, 155 (8.2%) with AL and 1745 without AL. Male gender, obesity, peritoneal contamination, year of surgery 2016–2020, duration of primary surgery and age remained significant predictors for AL in multivariate analysis. There was no significant difference in overall pre- and intraoperative compliance to ERAS®Society guidelines between groups. Only preadmission patient education remained as a significant ERAS variable associated with less AL. AL was associated with longer length of stay (LOS), higher morbidity rate and higher rate of reoperations. Conclusion Male gender, obesity, peritoneal contamination, duration of surgery, surgery later in study period, age and preadmission patient education were associated with AL in patients operated on with AR. Overall pre- and intraoperative compliance to the ERAS protocol was high in both groups and not associated with AL.

Hubungan Onset Keluhan Nyeri Perut dan Jumlah Leukosit dengan Tingkat Keparahan Apendisitis Akut pada Anak

Acute appendicitis always need surgical treatment. If appendectomy is not performed immediately, perforation of appendix and peritoneal contamination will complicate the disease. The highest incidence of appendicitis is in late teen, with 5% incidence in children under 5 years old. The aim of this study was to determine the correlation between onset of abdominal pain with the severity of pediatric acute appendicitis and to know the different of average leukocyte count of pediatric acute appendicitis between appendicitis and appendicitis complication. This study was analytical comparative and analytical correlative with retrospective approach. About 68 medical records of pediatric acute appendicitis patient in Arifin Achmad General Hospital Riau Province period January 2018 – December 2019 were analyzed. The result showed appendicitis case in children was same affected girls and boys mostly in group age 6-12 years old. Onset of abdominal pain was mostly after 48 hours of the disease. About 69.1% patient was suffering of appendicitis complication. Leukocytosis was found in 76.5% patients. Statistics analysis using unpaired t test showed p=0.00, it meant a significant different of average leukocyte count between appendicitis and appendicitis complication. IC95%=4015.7-6683.1. Statistics analysis using Somers’d correlative test show p=0.00. From this study, it can be concluded that there was a significant different of average leukocyte count between appendicitis and appendicitis complication also there was a significant correlation between onset of abdominal pain with severity of pediatric acute appendicitis with strong power correlation.

Enterostomies for acute abdominal surgical condition in children: An experience in a developing country

Background: Pediatric abdominal surgical condition that is complicated by gross peritoneal contamination may require enterostomy as a damage control or salvage procedure. Late presentations mostly seen in developing countries make creation of enterostomy a relatively common surgical procedure. The aim of this study was to evaluate the creation of enterostomy in children who presented with acute abdominal surgical conditions. Methods: This was a retrospective study of children that had enterostomy in the pediatric surgery unit of Enugu State University Teaching Hospital, Enugu, Nigeria. Medical records of pediatric patients that had enterostomy over a 10-year period were assessed. Results: There were 32 cases of enterostomies performed during the study period. There were 25 males (78.1%) and 7 females (21.9%) with a male to female ratio of 3.6:1. The age range of the patients was 3 weeks to 180 months, with a median age of 96 months. There were 1 neonate (3.1%), 10 infants (31.3%) and 21 children (65.6%) older than 1 year. The primary diagnoses were typhoid intestinal perforation in 21 patients (65.6%), intussusception 10 (31.3%) and intestinal atresia 1 (3.1%). Ileostomy was performed in 31 patients (96.9%) and jejunostomy in 1 patient (3.1%). Enterostomy was created at the time of initial laparotomy (damage control) in 21 patients (65.6%) while 11 patients (34.4%) had their enterostomy as a salvage procedure at the time of re-exploration. Peristomal skin complication was the most common complication recorded in our patients. Mortality was 12.5%. Conclusion: Enterostomy is lifesaving in the management of acute abdominal surgical condition when there is gross peritoneal contamination in severely ill children. Proper surgical technique and electrolyte derangements are important considerations when enterostomies are created.