Grenzen des laparoskopischen Operierens bei abdomineller Sepsis

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Abstract

Hintergrund: Zahlreiche präklinische Daten weisen auf Vorteile des laparoskopischen Operierens auch bei abdomineller Sepsisquelle und septischem Patienten hin. Methode und Ergebnisse: Anhand derzeit verfügbarer Literatur betrachten wir die Möglichkeiten und Limitierungen laparoskopischen Operierens beim septischen Patienten mit abdominellem Fokus. Neben generellen Überlegungen werden im Speziellen das Vorgehen bei Appendizitis, Cholezystitis, perforiertem Ulkus, Sigmadivertikulitis und akuter Pankreatitis erörtert. Schlussfolgerungen: Erfahrene laparoskopische Chirurgen können die Sanierung der abdominellen Sepsisquelle bei Appendizitis, Cholezystitis, perforiertem Ulkus oder auch Sigmadivertikulitis sicher durchführen. Kombinationen aus interventionellen Techniken und minimal invasiven Operationen bieten insbesondere bei der perforierten Sigmadivertikulitis und bei infizierten Pankreasnekrosen innovative Ansätze, die derzeit in multizentrischen prospektiven Studien untersucht werden.

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Most cited references 28

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A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique.

Grace Davey, J Dawson, Alan Lau … (1996)

This study compares laparoscopic versus open repair and suture versus sutureless repair of perforated duodenal and juxtapyloric ulcers. The place of laparoscopic repair of perforated peptic ulcer followed by peritoneal toilet of the peritoneal cavity has been established. Whether repair of the perforated peptic ulcer by the laparoscopic approach is better than conventional open repair and whether sutured repair is better than sutureless repair are both undetermined. One hundred three patients were randomly allocated to laparoscopic suture repair, laparoscopic sutureless repair, open suture repair, and open sutureless repair. Laparoscopic repair of perforated peptic ulcer (groups 1 and 2) took significantly longer than open repair (groups 3 and 4; 94.3 +/ 40.3 vs. 53.7 +/ 42.6 minutes: Student's test, p < 0.001), but the amount of analgesic required after laparoscopic repair was significantly less than in open surgery (median 1 dose vs. 3 doses) (Mann-Whitney U test, p = 0.03). There was no significant difference in the four groups of patients in terms of duration of nasogastric aspiration, duration of intravenous drip, total hospital stay, time to resume normal diet, visual analogue scale score for pain in the first 24 hours after surgery, morbidity, reoperation, and mortality rates. Laparoscopic repair of perforated peptic ulcer is a viable option. Sutureless repair is as safe as suture repair and it takes less time to perform.

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Laparoscopic versus open appendectomy: a prospective randomized comparison.

Guo-Feng Chen, Bao Wang, Hou-Feng Zheng … (2010)

Whether laparoscopy offers a benefit over open surgery in the management of acute appendicitis or not remains a subject of controversy despite the publication of numerous randomized studies. This study aimed to compare laparoscopic appendectomy (LA) with open appendectomy (OA) and to ascertain its therapeutic benefit. Adult patients older than 14 years presenting with signs and symptoms suggestive of acute appendicitis were randomized to undergo either LA or OA from January 2006 to December 2007. Comparisons were based on operating time, time until return to a general diet, time until return to normal activity and work, length of hospital stay, billed charges, and postoperative complications. The study enrolled 220 patients: 108 to undergo OA and 112 to undergo LA. The groups were similar in terms of clinicopathologic characteristics. The operating time seemed to be shorter for the OA patients than for the LA patients, but the difference was not significant (LA, 30 +/- 15.2 min vs. OA, 28.7 +/- 16.3 min; p > 0.05). The hospital stay of 4.1 +/- 1.5 days for the LA group and 7.2 +/- 1.7 days for the OA group, and the difference was statistically significant (p 0.05). Wound infections were more common after OA (n = 14) than after LA (n = 0) (p < 0.05). Intraabdominal abscesses occurred for two patients in the LA group and nine patients in the OA group (p < 0.05). Postoperative ileus occurred with frequencies of 0% in the LA group and 7.4% in the OA group (p < 0.05). The rate for overall complications was significantly lower in the LA group. Laparoscopic appendectomy is a useful tool in the treatment of acute appendicitis. Its advantages lie in its minimal invasiveness, its better cosmetic outcome, its lower rate of complications based on surgical expertise and state-of-the-art equipment. It can be recommended as an adoptable method for the routine patient with appendicitis.

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Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach.

Farzana Rana, Deepak K. Bhasin, Mandeep Kang … (2013)

Initial management of severe acute pancreatitis (SAP) is conservative. As a step-up approach, percutaneous catheter drainage (PCD) with saline irrigation is reported to be effective. Factors leading to surgery are unclear. In this ongoing prospective study, 70 consecutive patients with SAP were recruited. As a step-up approach, all patients initially received medical management and later underwent PCD and surgery as per the indication. Of the 70 consecutive patients with SAP, 14 were managed medically, 29 managed with PCD alone, whereas 27 required surgery after initial PCD. Sepsis reversal was achieved with PCD alone in 62.5%. The curative efficacy of PCD alone was in 27 patients (48%). Overall mortality in the whole group was 24%. On univariate analysis, factors significantly affecting surgical intervention included initial acute physiology and chronic health evaluation (APACHE) II score, APACHE II score at first intervention, sepsis reversal by PCD within a week, number of organs failed, organ failure within a week of the onset of disease, number of bacteria isolated per patient, renal failure, respiratory failure, Escherichia coli, computerized tomography severity index score at admission, parenteral nutrition requirement before or after radiological intervention, maximum extent of necrosis of more than 50% of the pancreas, and extrapancreatic necrosis. On multivariate analysis, renal failure (P = -0.03), APACHE II score at first intervention (P = -0.006), and the number of bacteria isolated per patient (P = -0.01) remained independent predictors of surgery. An APACHE II score of more than 7.5 at first intervention (PCD) had the ability to predict surgery with a sensitivity of 88.9% and a specificity of 69%. PCD reversed sepsis in 62% and avoided surgery in 48% of the patients. Reversal of sepsis within a week of PCD, APACHE II score at first intervention (PCD), and organ failure within a week of the onset of disease could predict the need for surgery in the early course of disease.

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Journal ID (publisher-id): VIM

Journal ID (pmc): VIS

Journal ID (doi): 10.1159/issn.2297-4725

Title: Visceral Medicine

Publisher: S. Karger AG

ISBN: 978-3-318-02353-4

ISBN: 978-3-318-02354-1

ISSN (Print): 2297-4725

ISSN (Electronic): 2297-475X

Publication date Subscription-year: 2013

Publication date (Print): March 2013

Publication date (Electronic): 11 February 2013

Volume: 29

Issue: 1

Pages: 28-33

Affiliations

Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Deutschland

Article

Publisher ID: 347175 Other ID: Viszeralmedizin 2013;29:28-33

DOI: 10.1159/000347175

SO-VID: 20fda273-28a0-48a5-858c-60de47f52a1b

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Grenzen des laparoskopischen Operierens bei abdomineller Sepsis

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Most cited references 28

A randomized study comparing laparoscopic versus open repair of perforated peptic ulcer using suture or sutureless technique.

Laparoscopic versus open appendectomy: a prospective randomized comparison.

Predictors of surgery in patients with severe acute pancreatitis managed by the step-up approach.

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