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 Table of Contents  
Year : 2019  |  Volume : 52  |  Issue : 5  |  Page : 169-174

Factor influencing outcome of source control in the management of complicated intra-abdominal infection in Cipto Mangunkusumo University Hospital

Department of Surgery, Division of Digestive, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Indonesia

Date of Submission08-Nov-2018
Date of Decision08-Mar-2019
Date of Acceptance05-May-2019
Date of Web Publication25-Oct-2019

Correspondence Address:
Dr. Toar Jean Maurice Lalisang
Department of Surgery, Division of Digestive, Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jalan Diponegoro #71, Senen, Central Jakarta
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_122_18

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Background: Source control (SC) procedure aiming to control the morbidity and mortality is essential in managing complicated intra-abdominal infection (cIAI). This study aims to review factors influencing the outcome of SC in cIAI cases at Cipto Mangunkusumo Hospital.
Methods: CIAI patients undergoing SC procedure in 2017 in our hospital were retrospectively reviewed. Prevalence, etiology, demography, types of procedure, and outcomes were the variables subjected to analysis.
Results: There were 110 (11.7%) cIAI cases of 945 abdominal surgeries, comprised of 74 (67.3%) males and 36 (32.7%) females. Median age was 43.9 years, including 24.5% participants aged >60 years. The most common etiology of mortality in cIAI was postoperative infection (POI) (36.4%), and the most frequently affected organ was lower gastrointestinal tract (GIT) (23.6%), especially colon which contributed to high mortality rates (34.6%). Operative mortality in participants who underwent drainage and debridement was 36% and 16.5%. Klebsiella pneumonia (36%) and Candida spp. (28.6%) infections were found in patients with poor outcome. Overall mortality was 20.9%.
Conclusions: High rates of operative mortality commonly happened in emergency cases, relaparotomy, and cases treated with definitive procedure. Lower GIT cases had the highest frequency of cIAI. POI was the most common indication of SC procedure. Candida spp. and Klebsiella pneumonia infections were the most frequent organisms found with poor outcome. SC surgery was performed in all cIAIs.

Keywords: Complicated intra-abdominal infection, postoperative infection, source control

How to cite this article:
Lalisang TJ, Mazni Y, Jeo WS, Marbun VM. Factor influencing outcome of source control in the management of complicated intra-abdominal infection in Cipto Mangunkusumo University Hospital. Formos J Surg 2019;52:169-74

How to cite this URL:
Lalisang TJ, Mazni Y, Jeo WS, Marbun VM. Factor influencing outcome of source control in the management of complicated intra-abdominal infection in Cipto Mangunkusumo University Hospital. Formos J Surg [serial online] 2019 [cited 2020 Jul 2];52:169-74. Available from: http://www.e-fjs.org/text.asp?2019/52/5/169/269923

  Introduction Top

Adequate source control (SC) by surgical procedures aims to eliminate the source of infection and is essential in managing complicated intra-abdominal infection (cIAI) although these are supported by a few publications with a high level of evidence.[1],[2],[3],[4],[5] However, poor outcomes of cIAI management are still encountered despite the successful and adequate SC by surgery.[2],[6],[7]

CIAI is associated with high mortality and morbidity. It also requires multiple discipline approaches including surgeons, intensivists, and infectious disease specialists, tailoring the best management by giving an appropriate antibiotic, timely SC, which are expected to improve patients' condition and resulted in better outcomes.[2],[4],[8],[9],[10],[11]

SC can be done either right after recognizing the source of infection or after preparing patients into optimal condition according to updated sepsis guidelines.[1],[2],[4],[5],[9],[12],[13] The preparations and aimed conditions are quite different compared to other centers and related to Indonesian-specific unique characteristics.

This study aims to review the management of cIAI cases in 2017 at Cipto Mangunkusumo Hospital, Jakarta, and describes the prevalence, characteristics of the population, and factors that influence the outcome, which shall be used to improve our management quality.

  Methods Top

We collected data of patients in Cipto Mangunkusumo Hospital, Jakarta, with general peritonitis and other intra-abdominal infection, managed by surgical procedure in 2017. Prevalence, etiology, epidemiology, surgical procedure, and outcome were the variables subjected to analysis. The management of the participant followed the hospital standard operation procedure which was already approved by the medical hospital committee.

Ethical approval

This study was approved by local ethics committee of the institute (104/UN2.F1/ETIK/2017 obtained on 6th February 2017). Informed written consent was obtained from all patients prior to their enrollment in this study.

  Results Top

There were 945 performed abdominal surgical procedures in Cipto Mangunkusumo Hospital in 2017. A hundred and ten of 945 (11.7%) were participants with cIAI comprising of 74 (67.3%) males and 36 (32.7%) females. The average age was 43.9 years, ranging from 19 to 81 years, including 27 (24.5%) participants aged more than 60 years old. Seventy-five participants (68%) were admitted to the emergency ward, referred from other hospitals, and consulted by internists or obstetricians. The remaining 32% were surgical department inpatients.

The most common diagnosis of cIAI is infection related to the gastrointestinal tract (GIT) (76.3%) followed by hepatic-pancreatic-biliary (HPB) cases and 6 cases of abdominal trauma. In 50% of participants, hypoalbuminemia was noticed. Patients concomitant with malignancy were 21 (19.1%) cases. We classified cases by organ, underlying disease, and operative mortality in [Table 1]. The most common source of general peritonitis was small bowel and colon perforation, and the rest were HPB, gynecology, or abdominal wall cases. Twenty-four (21.8%) cases were diagnosed with tertiary peritonitis due to positive Candida culture and repeated laparotomy procedures. We had one case of spontaneous bacterial peritonitis in liver malignancy which was diagnosed intraoperatively and deceased several days after surgery.
Table 1: Organ origin, underlying disease, and operative mortality of complicated intra-abdominal infection

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There was neither abdominal compartment syndrome nor intra-abdominal hypertension as an indication for surgery. All abdominal trauma cases with apparent general peritonitis were treated with laparotomy, including one thoracoabdominal gunshot wound and two blunt traumas. Perforated peptic ulcer disease and perforated diverticulitis cases were increasing, compared to only 2 cases of perforated typhoid in a year. All cases of perforated peptic ulcer disease, with Boey score 2 or less, were treated using primary suture, patch, and no vagotomy. Two cases of perforated typhoid were found in 21 and 35-year-old patients. One patient was performed abdominal debridement, small bowel resection, and anastomosis, and the other was performed ileostomy after resection of the perforated loop. Patients were then treated with twice-daily 1 g injection of kemicetine and continued with four times daily 500 mg chloramphenicol per oral. Both patients survived and discharged in good condition.

Hospital-acquired associated infection or abdominal postoperative infection (POI) was the most frequent indication for the surgical procedure, followed by community-acquired infection (CAI) such as small bowel perforations, perforated peptic ulcer disease, perforated appendix, colonic diverticulitis, and liver abscess. Causes and mortality rate of the infection are presented in [Table 2].
Table 2: Causes of complicated intra-abdominal infection and mortality rate

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There were 5 operative mortalities of 21 malignancy comorbid cIAI patients. Percutaneous drainage was not performed due to obvious signs of peritonitis in most cases. Various procedures for different cases of organs were performed, such as diversion or stoma for colonic cases and definitive procedures for perforated appendicitis, peptic ulcer, and typhoid [Table 3].
Table 3: Procedure of source control and operative mortality

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Due to high degree of severity of cases, we did not perform laparoscopy in emergency patients with clear sign of peritonitis. Relaparotomy was performed on 20 participants, 14 males and 6 females with average age of 49.5 years. Bowel perforation or leakage as the source of problem was 90% of indications of relaparotomy, and the rest were necrotic pancreatitis, abdominal fasciitis, and bile leaks. Six patients did not survive due to unresponsiveness to sepsis treatment on POI cases.

Overall mortality in this study was 20.9% (n = 23), with average age of 47.1 years. The most common cases were colonic cases, predominantly Hinchey Type 4 diverticulitis. Nineteen of 23 participants who did not survive were in critical condition and already diagnosed with septic shock on admission.

There are 40.9% of overall cases available with culture reports and 84% of those were positive with bacterial growth, including five Candida positive cases. The most common microbes found were Klebsiella pneumoniae, Staphylococcus spp.,  Escherichia More Details coli, Pseudomonas aeruginosa, and Acinetobacter spp. [Table 4].
Table 4: Microbiogram and mortality cases

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[Table 5] presents survival and mortality rate grouped by age, ASA classification, emergency condition, and relaparotomy procedures. It shows that 6 of 23 (26.1%) patients underwent relaparotomy and 18 of 23 (78.2%) patients admitted in emergency setting were deceased. However, these differences were not statistically significant (P > 0.05).
Table 5: Survival and mortality rate

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  Discussion Top

The prevalence of cIAI in our hospital was 11.7% which were in range with the previous reports. The difference was the causes of infection. Other publications reported acute appendicitis and cholecystitis/CAI as the most common cause while POI or hospital-acquired associated infections (HAAIs) was the most common cIAI cause in this report.[8],[10],[14],[15],[16]

Biliary duct infection as the cause of cIAI was not presented in most publications as well, due to different grouping of the disease.[14] We categorized biliary duct infection as one variable including acute cholecystitis and cholangitis.

Perforated typhoid, which peaked in the 1980s, was found less frequently compared to other countries' publications.[4],[15],[16],[17] There were only two cases in 2017, which both survived unremarkably and discharged with oral chloramphenicol. This declined number correlates to national better hygiene, compulsory prevention, and successful eradication with oral antibiotics at regional hospital and primary health care. Both males were adult 21 and 35 years which are uncommon ages according to report from Tanzania and Kenya, similar to Indonesia as countries in the equator region. High percentage of CAI (36.6%), such as acute appendicitis, perforated peptic ulcer, and perforated colonic diverticulitis was also noted.

The different etiology of cIAI in this report was due to our hospital characteristic, as the tertiary academic referral hospital which accepted complex and severe cases. Many community-acquired intra-abdominal infections were treated in secondary care hospital and referred to us when complications occurred.

There were differences found in age as well. CIAOW study in 2014 reported cIAI happened in older age (51.6 vs. 43.9 years).[14] Elderly patients are associated with high mortality due to poor physiological function and ability to fight the insult in septic process.[18] This study showed higher mortality rate in patients aged 60 years and older (29.6% vs. 18.1%). This group was likely to undergo relaparotomy as well (22.2% vs. 18.1%) that showed poor immune system after insult and confirmed presence of higher risk of failure in managing cIAI. High rates of mortality happened in HAAIs which were aligned with risk factors of treatment failure of cIAI.[5],[8],[14] POI, as a single entity in HAAI, had the highest mortality rate compared to acute appendicitis with perforation, as the most common cause of community-acquired intra-abdominal infection (34.7% vs. 0), confirmed by the positive impact of HAAI to mortality.[2],[4],[14] Inui stated that mortality is associated with the presence of organ dysfunction rather than the source of infection.[19] This is why patients with POI with persistent sepsis who often sustained organ failure had higher risk of mortality.

The majority of the underlying disease of cIAI in this study were GIT malignancy (19.1%) in which 50% had hypoalbuminemia as a comorbid, alleviating treatment and naturally affecting the outcome. Seventy-eight percent of emergency cases presented obvious peritonitis, thus excluding delay of diagnosis as a worsening factor. Preparation of patients to be in at least suboptimal condition facing surgery was still a problem we encountered. Delay mostly happened due to nonmedical problems such as waiting for OR, intensive care unit (ICU), and patients' agreement for operative procedures.

Surgical SC was performed in all participants through median laparotomy as important steps to cutoff the sepsis cascade. Laparoscopy procedure was not chosen due to severe condition and massive contamination which unfortunately happened in all participants. Quick in and quick out laparotomy was the selected strategy to avoid prolonged operation time and adequate cleansing of abdominal cavity with 4 L of ringer lactate solution was used to dilute intra-abdominal contamination. We believe that open approach can gain better cleansing in patients with massive contamination in whole abdominal quadrant. WSES 2017 stated that laparoscopic peritoneal lavage may not be considered the treatment of choice in patients with diffuse peritonitis. Laparoscopy also may have negative effect in critically ill patients, leading to acid–base balance disturbances, as well as changes in cardiovascular and pulmonary physiology.

In this study, most cIAI presented in septic condition. Thirteen cases of perforated appendicitis, 11 cases of perforated peptic ulcer, and 2 perforated typhoid were performed definitive surgery. Definitive treatment combined with debriding were also performed in bowel perforation with extensive abdominal contamination. Diversion with proximal stoma was done in all bowel perforations with severe abdominal contamination.

We noticed high mortality rate (>50%), especially in perforated colonic diverticulitis Hinchey Type 4, treated “over-treatmently” by doing abdominal debridement simultaneously with bowel resection which prolonged duration of operation and depressed the defense mechanism further. This kind of definitive treatment worsened septic process that led to mortality. Perforated diverticulitis can be managed without definitive SC in highly selected patients if responding well to antibiotics.[4]

Damage control surgery concept was applied in our routine despite high mortality rate, for instance, in late-infected HPB trauma and perforated peptic ulcer. Perforated peptic ulcer Boey score 3 was managed according to sepsis guidelines, by performing bedside abdominal drainage in ICU while preparing patients toward surgery.[5] This concept of damage control surgery in cIAI is matched with our aphorism, and “safe surgery is better than excellent surgery,” followed by definitive surgery done within 48 h.

There is a promising method of damage control surgery, which is staged surgery, consisting of initial debridement, lavage and drainage, and temporary abdominal closure, followed by intensive care and administration of proper therapeutic antibiotic.[2],[20]

SC and antimicrobial therapy should be tailor-made based on the assessment of risk of outcome, especially in cIAI patients with sepsis or septic shock.[4] In our study, definitive treatment after staged surgery was only applied in patients with highly severe condition. That is why it was not performed in perforated appendicitis, perforated peptic ulcer Boey score <2, and liver abscess.

Relaparotomy was performed in 20% of total participants in which 6 did not survive. Modified Abdominal Reoperation Predictive Index was used to aid decision-making of timing of on-demand relaparotomy. Planned relaparotomy was performed in only two cases which results in good outcome. Patients who underwent relaparotomy were patients who initially performed drainage and debridement (88.3%) with postoperative persistent sepsis as surgical indication.

Overall mortality in this study is double of that reported in CIAOW study (20.9% vs. 10.5%).[14] Of 23 mortality cases, more than three-quarters of those were emergency cases (78.3%, n = 18), and 87% of total deceased patients were classified into ASA three group. These represent complex cases and high degree of severity which were usually found in tertiary referral hospital like our center, previously treated inadequately by primary or secondary care center in terms of not only antibiotic and fluid administration but also misdiagnosis. This is the reason why only minor group of our patients came with early presentation of infection. More than half participants (65.2%) who underwent definitive treatment were deceased. This high mortality rate shows that definitive treatment strategy has to be reconsidered in severe cases.[20]

Although only 34% cases are available with microbiology culture report, microbes found in this study can represent Indonesia and quite smilar to other worldwide references. There are ten types of bacteria, predominantly Streptococcus spp. as the most common source of upper GIT infection, followed by K. pneumoniae found in colonic cases. Streptococcus, Staphylococcus, and Pseudomonas were confirmed as nosocomial infection, whereas Gram-negative aerobe microbes were compatible with source of infection.

Aminoglycoside was given as the first-line empirical antibiotic, in line with hospital's microbial profile. Carbapenem, cephalosporin, and tigecycline are administered as the second-line choice of therapeutic antibiotic, similar to other centers in other part of the world. Montravers recommended no prolonged antibiotic administration more than 8 days, for no clinical benefit encountered.[21] Duration of antibiotic cannot be evaluated according to Gyssens protocol due to limited data, but based on medical records, all patients received intravenous antibiotic more than 10 days and then discharged with oral antibiotic, confirming no relation to mortality rate.

Finally, in-hospital mortality occurred mostly on emergency cases, with colon as the most common source and POI as the most common indication. Mortality also occurred after definitive SC procedure, with Klebsiella pneumonia as the most common microbial cause of death. Relaparotomy was also associated with high rates of mortality in cIAI.

  Conclusions Top

High rates of operative mortality commonly occurred on emergency cases, relaparotomy, and cases treated with defined procedure. Lower GIT cases had the highest frequency of cIAI. POI was the most common indication of SC procedure. Candida spp. and Klebsiella pneumonia infections were the most frequent organisms found with poor outcome. SC surgery was performed in all cIAIs. Aminoglycoside and metronidazole were used as the first-line treatment.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Wieghard N, Geltzeiler CB, Tsikitis VL. Trends in the surgical management of diverticulitis. Ann Gastroenterol 2015;28:25-30.  Back to cited text no. 17
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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