Curso clínico de la peritonitis grave en pacientes críticamente enfermos tratados con sutura primaria diferida
Palabras clave:
peritonitis, evolución clínica, mortalidad, laparotomía, técnicas de suturaResumen
Introducción. La anastomosis primaria es una técnica posible en el manejo de la peritonitis secundaria grave en pacientes críticamente enfermos; sin embargo, su uso se ha limitado por el riesgo de complicaciones y muerte.
Materiales y métodos. Se seleccionaron pacientes con peritonitis secundaria grave que requerían resección de un segmento del intestino y se manejaron con ligadura transitoria de intestino con hiladilla, abdomen abierto, laparotomías múltiples programadas y posterior anastomosis primaria diferida. Como éxito primario se definió aquel caso en el cual se logró hacer la anastomosis y no tuvo filtración ni fístula.
Resultados. Se estudiaron 26 pacientes. El APACHE II promedio fue de 15,3 puntos. Se practicaron 14 anastomosis enteroentéricas, 5 anastomosis colocólicas y 4 anastomosis ileocólicas, y en 3 pacientes no se pudo hacer anastomosis. En promedio, hubo 4 laparotomías múltiples programadas por paciente que se realizaron cada 24 horas antes de la anastomosis.
El éxito primario se logró en 20 pacientes (77%). La supervivencia a los 28 días fue de 88,4%, 23 pacientes egresaron vivos y sólo 3 (11,5%) fallecieron en la unidad de cuidados intensivos; estas muertes fueron independientes del procedimiento.
Discusión. En pacientes con peritonitis secundaria grave la estrategia de control de daños fue viable y segura, con un éxito primario de 77%, con fístula en 11,5%, y mortalidad de 11,5%.
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Referencias bibliográficas
1. Mastboom WJ, Kuypers HH, Schoots FJ, Wobbes T. Small-bowel perforation complicating the open treatment of generalized peritonitis. Arch Surg. 1989; 124:689-92.
2. Schein M, Saadia R, Freinkel Z, Decker GA. Aggressive treatment of severe diffuse peritonitis: a prospective study. Br J Surg. 1988; 75:173-6.
3. Wittman DH, Aprehamian C, Bergstein JM. Etappenlavage: advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and Velcro analogue for temporary abdominal closure. World J Surg. 1990; 14:218-26.
4. Patiño JF, Quintero G, Baptiste S. Infección quirúrgica. En: Patiño JF, editor. Lecciones en cirugía. Bogotá: Editorial Médica Panamericana; 2000. p. 105-17.
5. Anaya DA, Nathens A. Risk factors for severe sepsis in secondary peritonitis. Surg Infect. 2003; 4:355-62.
6. Hotchkiss R, Karl I. Medical progress: the pathophysiology and treatment of sepsis. N Engl J Med. 2003; 348:138-50.
7. Marshall J, Innes M. Intensive care unit management of intra-abdominal infection. Crit Care Med. 200; 31:2228-37.
8. Paugam-Burtz C, Dupont H, Marmuse JP, Chosidow D, Malek L, Desmonts JM, et al. Daily organ-system failure for diagnosis of persistent intra-abdominal sepsis after postoperative peritonitis. Intensive Care Med. 2002; 28:594-8.
9. Riche FC, Cholley BP, Panis YH, Laisne MJ, Briard CG, Graulet AM, et al. Inflammatory cytokine response in patients with septic shock secondary to generalized peritonitis. Crit Care Med. 2000; 28(2):433-7.
10. Borráez OA. Peritonitis terciaria. En: Quintero G, Nieto J, Lerma C., editor. Infección en cirugía. Bogotá: Editorial Médica Panamericana; 2001. p. 238-44.
11. Borráez OA. Abdomen abierto. En: Quintero G, Nieto J, Lerma C., editor. Infección en cirugía. Bogotá: Editorial Médica Panamericana; 2001. p. 230-7.
12. Nieto JA. Sepsis abdominal. Urgencias médico-quirúrgicas. Bogotá: Editorial Distribuna; 2002. p. 189-98.
13. Ordóñez CA, Franco JE. Peritonitis y sepsis intraabdominal. En: ¿editores? Cuidado intensivo y trauma. Bogotá: Editorial Distribuna; 2003. p. 667-84.
14. Uribe R. Sepsis abdominal. Tópicos en Medicina Intensiva. 2003; 2:195-203.
15. Bulger EM, McMahon K, Jurkovich GJ. The morbidity of penetrating colon injury. Injury. 2003; 34:41-6.
16. Curran TJ, Brozota A. Complications of primary repair of colon injury: literature review of 2,964 cases. Am J Surg. 1999; 177:42-7.
17. González RP, Falimirski ME, Holevar MR. Further evaluation of colostomy in penetrating colon injury. Am Surg. 2000; 66:342-6.
18. Nespoli A, Ravizzini C, Trivella M, Segala M. The choice of surgical procedure for peritonitis due to colonic perforation. Arch Surg. 1993; 128:814-8.
19. Ravo B, Metwally N, Castera P, Polansky PJ, Ger R. The importance of intraluminal anastomotic fecal contact and peritonitis in colonic anastomotic leakages. An experimental study. Dis Colon Rectum. 1988; 31:868-71.
20. Schilling MK, Maurer CA, Kollmar O, Buchler MW. Primary Vs. secondary anastomoses after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV): a prospective outcome and cost analysis. Dis Colon Rectum. 2001; 44:699-703.
21. Edwards DP, Leppington-Clarke A, Sexton R, Heald RJ, Moran BJ. Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Br J Surg. 2001; 88:360-3.
22. Biondo S, Jaurrieta E, Jorba R, Moreno P, Farran L, Borobia F, et al. Intraoperative colonic lavage and primary anastomoses in peritonitis and obstruction. Br J Surg. 1997; 84:222-5.
23. Biondo S, Perea MT, Rague JM, Pares D, Jaurrieta E. One-stage procedure in non-elective surgery for diverticular disease complications. Colorectal Dis. 2001; 3:42-5.
24. Zorcolo L, Covotta L, Carlomagno N, Bartolo DC. Safety of primary anastomoses in emergency colo-rectal surgery. Colorectal Dis. 2003; 5:262-9.
25. Chappuis CW, Frey DJ, Dietzen CD, Panetta TP, Buechter KJ, Cohn I, Jr. Management of penetrating colon injuries. A prospective randomized trial. Ann Surg. 1991; 213:492-7.
26. Demetriades D, Murray JA, Chan L, Ordóñez C, Bowley D, Nagy KK, et al. Penetrating colon injuries requiring resection: diversion or primary anastomoses? An AAST prospective multicenter study. J Trauma. 2001; 50:765-75.
27. González RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: is it necessary? J Trauma. 1996; 41:271-5.
28. Murray JA, Demetriades D, Colson M, Song Z, Velmahos GC, Cornwell EE, III et al. Colonic resection in trauma: colostomy versus anastomoses. J Trauma. 1999; 46:250-4.
29. Nelson R, Singer M. Primary repair for penetrating colon injuries. Cochrane Database Syst Rev. 2002; (3):CD002247.
30. Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: a prospective randomized study. J Trauma. 1995; 39:895-901.
31. Singer MA, Nelson RL. Primary repair of penetrating colon injuries: a systematic review. Dis Colon Rectum. 2002; 45:1579-87.
32. Adkins AL, Robbins J, Villalba M, et al. Open abdomen management of intra-abdominal sepsis. Am Surg. 2004; 70:137-40.
33. Aprahamian C, Wittman D, Berstein JM. Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma. J Trauma. 1990; 30:719-23.
34. Bosscha K, Hulstaert PF, Visser MR, et al. Open management of the abdomen and planned reoperations in severe bacterial peritonitis. Eur J Surg. 2000; 166:44-9.
35. Hau T, Ohmann C, Wolmershauser A, et al. Planned relaparotomy Vs. relaparotomy on demand in the treatment of intra-abdominal infections. The Peritonitis Study Group of the Surgical Infection Society-Europe. Arch Surg. 1995; 130:1193-7.
36. Holzheimer RG, Gathof B. Re-operation for complicated secondary peritonitis - how to identify patients at risk for persistent sepsis. Eur J Med Res. 2003; 27:125-34.
37. Koperna T, Schulz F. Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg. 2000; 24:32-7.
38. Lamme B, Boermeester MA, Reitsma JB, et al. Meta-analysis of relaparotomy for secondary peritonitis. Br J Surg. 2002; 89:1516-24.
39. McPartland KJ, Hyman NH. Damage control: what is its role in colorectal surgery? Dis Colon Rectum. 2003; 46:981-6.
40. Penninckx FM, Kerremans RP, Lauwers PM. Planned relaparotomies in the surgical treatment of severe generalized peritonitis from intestinal origin. World J Surg. 1983; 7:762-6.
41. Rotondo M, Schwab CW, McGonigal M, et al. «Damage Control»: An approach for improved survival in exsanguinations penetrating abdominal injury. J Trauma. 1993; 35:375.
42. Rotondo MF, Zomies D. The damage control sequence and underlying logic. Surg Clin North Am. 2005; 77:761-77.
43. Schein M. Surgical management of intra-abdominal infection: is there any evidence? Langenbecks Arch Surg. 2002; 387:1-7.
44. Schreiber M. Damage Control Surgery. Crit Care Clin. 2005; 20:101-18.
45. Schwartz A, Onaca N, Rabi I, et al. Closure of the abdomen by mesh for planned re-laparotomy. A technical modification. Int Surg. 1997; 82:42-3.
46. Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care. 2005; 11:333-8.
47. Burch J, Franciose R, Moore E, Biffl W, Offner P. Single-layer continuous versus two-layer interrupted intestinal anastomoses: a prospective randomized trial. Ann Surg. 2000; 231:832-7.
48. de Graaf JS, van Goor H, Bleichrodt RP. Primary small bowel anastomosis in generalizad peritonitis. Eur J Surg. 1996; 162:55-8.
49. Moriura S, Kobayashi I, Ishiguro S, Tabata T, Yoshioka Y, Matsumoto T. Continuous mattress suture for all hand-sewn anastomoses of the gastrointestinal tract. Am J Surg. 2002; 184:446-8.
50. Rotstein OD, Pruett TL, Simmons RL. Microbiologic features and treatment of persistent peritonitis in patients in the intensive care unit. Can J Surg. 1986; 29:247-50.
51. Solomkin J, Yellin A, Rotstein O, Christou N, Dellinger E, Tellado J, Malafaia O, Fernández A, Choe K, Carides A, Satishchandran V, Teppler H. The Protocol 017 Study Group. Ertapenem versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections: results of a double-blind, randomized comparative phase III trial. Ann Surg. 2003; 237:235-45.
52. Visser MR, Bosscha K, Olsman J, et al. Predictors of recurrence of fulminant bacterial peritonitis after discontinuation of antibiotics in open management of the abdomen. Eur J Surg. 1998; 164:825-9.
53. Biondo S, Jaurrieta E, Jorba R, Moreno P, Farran L, Borobia F, Bettonica C, Poves I, Ramos E, Alcobendas F. Role of resection and primary anastomosis of the left colon in the presence of peritonitis. Br J Surg. 2000; 87:1580-4.
54. Christou NV, Barie PS, Dellinger EP, Waymack JP, Stone HH. Surgical infection Society intra-abdominal infection study. Prospective evaluation of management techniques and outcome. Arch Surg. 1993; 128:193-9.
55. Wittmann D. Newer methods of operative therapy for peritonitis: Open abdomen, planned relaparotomy or staged abdominal repair (STAR). In: Tellado J, Christou N. Intra-abdominal Infections. Madrid: Hartcourt; 2000. p. 153-177.
56. Rivers E, Nguyen B, Havstad S, et al. Early goal-direct therapy in the treatment of severe sepsis and septic shock. N Eng J Med. 2001; 345:1368-77.
57. Shapiro M, Jenkins D, Schwab W, Rotondo M. Damage control: Collective review. J Trauma. 2000; 49:969-78.
58. Johnson J, Gracias V, Schwab W, Reilly P. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma. 2001; 51:261-71.
2. Schein M, Saadia R, Freinkel Z, Decker GA. Aggressive treatment of severe diffuse peritonitis: a prospective study. Br J Surg. 1988; 75:173-6.
3. Wittman DH, Aprehamian C, Bergstein JM. Etappenlavage: advanced diffuse peritonitis managed by planned multiple laparotomies utilizing zippers, slide fastener, and Velcro analogue for temporary abdominal closure. World J Surg. 1990; 14:218-26.
4. Patiño JF, Quintero G, Baptiste S. Infección quirúrgica. En: Patiño JF, editor. Lecciones en cirugía. Bogotá: Editorial Médica Panamericana; 2000. p. 105-17.
5. Anaya DA, Nathens A. Risk factors for severe sepsis in secondary peritonitis. Surg Infect. 2003; 4:355-62.
6. Hotchkiss R, Karl I. Medical progress: the pathophysiology and treatment of sepsis. N Engl J Med. 2003; 348:138-50.
7. Marshall J, Innes M. Intensive care unit management of intra-abdominal infection. Crit Care Med. 200; 31:2228-37.
8. Paugam-Burtz C, Dupont H, Marmuse JP, Chosidow D, Malek L, Desmonts JM, et al. Daily organ-system failure for diagnosis of persistent intra-abdominal sepsis after postoperative peritonitis. Intensive Care Med. 2002; 28:594-8.
9. Riche FC, Cholley BP, Panis YH, Laisne MJ, Briard CG, Graulet AM, et al. Inflammatory cytokine response in patients with septic shock secondary to generalized peritonitis. Crit Care Med. 2000; 28(2):433-7.
10. Borráez OA. Peritonitis terciaria. En: Quintero G, Nieto J, Lerma C., editor. Infección en cirugía. Bogotá: Editorial Médica Panamericana; 2001. p. 238-44.
11. Borráez OA. Abdomen abierto. En: Quintero G, Nieto J, Lerma C., editor. Infección en cirugía. Bogotá: Editorial Médica Panamericana; 2001. p. 230-7.
12. Nieto JA. Sepsis abdominal. Urgencias médico-quirúrgicas. Bogotá: Editorial Distribuna; 2002. p. 189-98.
13. Ordóñez CA, Franco JE. Peritonitis y sepsis intraabdominal. En: ¿editores? Cuidado intensivo y trauma. Bogotá: Editorial Distribuna; 2003. p. 667-84.
14. Uribe R. Sepsis abdominal. Tópicos en Medicina Intensiva. 2003; 2:195-203.
15. Bulger EM, McMahon K, Jurkovich GJ. The morbidity of penetrating colon injury. Injury. 2003; 34:41-6.
16. Curran TJ, Brozota A. Complications of primary repair of colon injury: literature review of 2,964 cases. Am J Surg. 1999; 177:42-7.
17. González RP, Falimirski ME, Holevar MR. Further evaluation of colostomy in penetrating colon injury. Am Surg. 2000; 66:342-6.
18. Nespoli A, Ravizzini C, Trivella M, Segala M. The choice of surgical procedure for peritonitis due to colonic perforation. Arch Surg. 1993; 128:814-8.
19. Ravo B, Metwally N, Castera P, Polansky PJ, Ger R. The importance of intraluminal anastomotic fecal contact and peritonitis in colonic anastomotic leakages. An experimental study. Dis Colon Rectum. 1988; 31:868-71.
20. Schilling MK, Maurer CA, Kollmar O, Buchler MW. Primary Vs. secondary anastomoses after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV): a prospective outcome and cost analysis. Dis Colon Rectum. 2001; 44:699-703.
21. Edwards DP, Leppington-Clarke A, Sexton R, Heald RJ, Moran BJ. Stoma-related complications are more frequent after transverse colostomy than loop ileostomy: a prospective randomized clinical trial. Br J Surg. 2001; 88:360-3.
22. Biondo S, Jaurrieta E, Jorba R, Moreno P, Farran L, Borobia F, et al. Intraoperative colonic lavage and primary anastomoses in peritonitis and obstruction. Br J Surg. 1997; 84:222-5.
23. Biondo S, Perea MT, Rague JM, Pares D, Jaurrieta E. One-stage procedure in non-elective surgery for diverticular disease complications. Colorectal Dis. 2001; 3:42-5.
24. Zorcolo L, Covotta L, Carlomagno N, Bartolo DC. Safety of primary anastomoses in emergency colo-rectal surgery. Colorectal Dis. 2003; 5:262-9.
25. Chappuis CW, Frey DJ, Dietzen CD, Panetta TP, Buechter KJ, Cohn I, Jr. Management of penetrating colon injuries. A prospective randomized trial. Ann Surg. 1991; 213:492-7.
26. Demetriades D, Murray JA, Chan L, Ordóñez C, Bowley D, Nagy KK, et al. Penetrating colon injuries requiring resection: diversion or primary anastomoses? An AAST prospective multicenter study. J Trauma. 2001; 50:765-75.
27. González RP, Merlotti GJ, Holevar MR. Colostomy in penetrating colon injury: is it necessary? J Trauma. 1996; 41:271-5.
28. Murray JA, Demetriades D, Colson M, Song Z, Velmahos GC, Cornwell EE, III et al. Colonic resection in trauma: colostomy versus anastomoses. J Trauma. 1999; 46:250-4.
29. Nelson R, Singer M. Primary repair for penetrating colon injuries. Cochrane Database Syst Rev. 2002; (3):CD002247.
30. Sasaki LS, Allaben RD, Golwala R, Mittal VK. Primary repair of colon injuries: a prospective randomized study. J Trauma. 1995; 39:895-901.
31. Singer MA, Nelson RL. Primary repair of penetrating colon injuries: a systematic review. Dis Colon Rectum. 2002; 45:1579-87.
32. Adkins AL, Robbins J, Villalba M, et al. Open abdomen management of intra-abdominal sepsis. Am Surg. 2004; 70:137-40.
33. Aprahamian C, Wittman D, Berstein JM. Temporary abdominal closure (TAC) for planned relaparotomy (etappenlavage) in trauma. J Trauma. 1990; 30:719-23.
34. Bosscha K, Hulstaert PF, Visser MR, et al. Open management of the abdomen and planned reoperations in severe bacterial peritonitis. Eur J Surg. 2000; 166:44-9.
35. Hau T, Ohmann C, Wolmershauser A, et al. Planned relaparotomy Vs. relaparotomy on demand in the treatment of intra-abdominal infections. The Peritonitis Study Group of the Surgical Infection Society-Europe. Arch Surg. 1995; 130:1193-7.
36. Holzheimer RG, Gathof B. Re-operation for complicated secondary peritonitis - how to identify patients at risk for persistent sepsis. Eur J Med Res. 2003; 27:125-34.
37. Koperna T, Schulz F. Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg. 2000; 24:32-7.
38. Lamme B, Boermeester MA, Reitsma JB, et al. Meta-analysis of relaparotomy for secondary peritonitis. Br J Surg. 2002; 89:1516-24.
39. McPartland KJ, Hyman NH. Damage control: what is its role in colorectal surgery? Dis Colon Rectum. 2003; 46:981-6.
40. Penninckx FM, Kerremans RP, Lauwers PM. Planned relaparotomies in the surgical treatment of severe generalized peritonitis from intestinal origin. World J Surg. 1983; 7:762-6.
41. Rotondo M, Schwab CW, McGonigal M, et al. «Damage Control»: An approach for improved survival in exsanguinations penetrating abdominal injury. J Trauma. 1993; 35:375.
42. Rotondo MF, Zomies D. The damage control sequence and underlying logic. Surg Clin North Am. 2005; 77:761-77.
43. Schein M. Surgical management of intra-abdominal infection: is there any evidence? Langenbecks Arch Surg. 2002; 387:1-7.
44. Schreiber M. Damage Control Surgery. Crit Care Clin. 2005; 20:101-18.
45. Schwartz A, Onaca N, Rabi I, et al. Closure of the abdomen by mesh for planned re-laparotomy. A technical modification. Int Surg. 1997; 82:42-3.
46. Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care. 2005; 11:333-8.
47. Burch J, Franciose R, Moore E, Biffl W, Offner P. Single-layer continuous versus two-layer interrupted intestinal anastomoses: a prospective randomized trial. Ann Surg. 2000; 231:832-7.
48. de Graaf JS, van Goor H, Bleichrodt RP. Primary small bowel anastomosis in generalizad peritonitis. Eur J Surg. 1996; 162:55-8.
49. Moriura S, Kobayashi I, Ishiguro S, Tabata T, Yoshioka Y, Matsumoto T. Continuous mattress suture for all hand-sewn anastomoses of the gastrointestinal tract. Am J Surg. 2002; 184:446-8.
50. Rotstein OD, Pruett TL, Simmons RL. Microbiologic features and treatment of persistent peritonitis in patients in the intensive care unit. Can J Surg. 1986; 29:247-50.
51. Solomkin J, Yellin A, Rotstein O, Christou N, Dellinger E, Tellado J, Malafaia O, Fernández A, Choe K, Carides A, Satishchandran V, Teppler H. The Protocol 017 Study Group. Ertapenem versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections: results of a double-blind, randomized comparative phase III trial. Ann Surg. 2003; 237:235-45.
52. Visser MR, Bosscha K, Olsman J, et al. Predictors of recurrence of fulminant bacterial peritonitis after discontinuation of antibiotics in open management of the abdomen. Eur J Surg. 1998; 164:825-9.
53. Biondo S, Jaurrieta E, Jorba R, Moreno P, Farran L, Borobia F, Bettonica C, Poves I, Ramos E, Alcobendas F. Role of resection and primary anastomosis of the left colon in the presence of peritonitis. Br J Surg. 2000; 87:1580-4.
54. Christou NV, Barie PS, Dellinger EP, Waymack JP, Stone HH. Surgical infection Society intra-abdominal infection study. Prospective evaluation of management techniques and outcome. Arch Surg. 1993; 128:193-9.
55. Wittmann D. Newer methods of operative therapy for peritonitis: Open abdomen, planned relaparotomy or staged abdominal repair (STAR). In: Tellado J, Christou N. Intra-abdominal Infections. Madrid: Hartcourt; 2000. p. 153-177.
56. Rivers E, Nguyen B, Havstad S, et al. Early goal-direct therapy in the treatment of severe sepsis and septic shock. N Eng J Med. 2001; 345:1368-77.
57. Shapiro M, Jenkins D, Schwab W, Rotondo M. Damage control: Collective review. J Trauma. 2000; 49:969-78.
58. Johnson J, Gracias V, Schwab W, Reilly P. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma. 2001; 51:261-71.
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Publicado
2008-03-20
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Ordóñez, C. A.; Pineda, J. A.; Arias, R. H.; Benítez, F. A.; Toro, L. E.; Aristizábal, G.; Martínez, J. E.; Rosso, F.; Granados, M.; Badiel, M. Curso clínico De La Peritonitis Grave En Pacientes críticamente Enfermos Tratados Con Sutura Primaria Diferida. Rev Colomb Cir 2008, 23, 22-30.
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