Abstract
Frequently, several multiple abdominal reexplorations are needed in patients with acute necrotizing hemorrhagic pancreatitis (ANP) or with persistent intraabdominal sepsis (PIAS). Residual undrained necrotic and septic foci lead to multiple organ failure. To provide wide-open drainage of the abdominal cavity, since 1985 we have performed sequential abdominal reexploration with the zipper technique (SARZT) in 24 patients.
Apache II score was used to evaluate expected mortality. In the pancreatic necrosis group, with a mean Apache II score of 31, the expected and the observed mortality were 70% and 29%, respectively. In the PIAS group, with a mean Apache II score of 30, the expected and observed mortality were 60 and 28%, respectively. These results are attributed to the sequential reexploration of the abdominal cavity that permits excision and drainage of necrotic and septic foci.
Résumé
Chez le patient qui a une pancréatite nécrosante (PN) ou une sepsis abdominale persistante (SAP), plusieurs interventions exploratrices sont parfois nécessaires. La persistance de foyers de nécrose ou d'infection peut provoquer une défaillance polyviscérale. Pour permettre, dans ces cas, un drainage large de la cavité abdominale, nous avons pratiqué une ré-exploration répétée systématique avec la technique de fermeture éclair (SARZT) chez 24 patients depuis 1985.
Le score Apache II était utilisé pour évaluer la mortalité attendue. Dans le groupe de patients avec une pancréatite aiguË, le score d'Apache II moyen était de 31; la mortalité attendue était de 70%, la mortalité réelle de 29%. Dans le groupe de patients avec SAP, le score Apache II moyen était de 30, la mortalité attendue de 60% et la mortalité réelle de 28%. Ces résultats favorables sont attribués à la technique de réexploration répétée de la cavité abdominale qui permet l'excision et le drainage efficace de tout foyer de nécrose ou de sepsis.
Resumen
Con frecuencia se requieren reexploraciones abdominales repetidas en pacientes con pancreatitis necrotizante hemorrágica (PNH) o con sepsis intra-abdominal persistente (SIAP). Focos necróticos y sépticos residuales no drenados inducen falla orgánica mÚltiple. Con el objeto de proveer drenaje abierto amplio de la cavidad abdominal, hemos realizado desde 1985 la reexploración abdominal secuencial por medio de la técnica del zipper en 24 pacientes.
Se utilizó el puntaje APACHE II para hacer la valorización de la mortalidad previsible. En el grupo de pacientes con necrosis pancreática el puntaje APACHE II promedio fue 31, y las tasas de mortalidad previsible y de mortalidad real fueron 70% y 29%, respectivamente. En el grupo con SIAP, con un puntaje APACHE II promedio de 30, las tasas de mortalidad previsible y de mortalidad real fueron 60% y 28%, respectivamente. Se atribuyen estos resultados a las reexploraciones secuenciales de la cavidad abdominal, las cuales permiten la remoción y drenaje de focos necróticos y sépticos.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Mughal, M.M., Bancewicz, J., Irving, M.H.: Laparotomy: A technique for the management of intractable intra-abdominal sepsis. Br J Surg73:253. 1986
Hedderich, G.S., Wexler, M.J., McLean, A.P.H., Meakins, J.L.: The septic abdomen: Open management with Marlex mesh with a zipper. Surgery99:399, 1986
Garcia Sabrido, J.L., Valdecantos, E., Tellado, J.M., Quintans, A., Ferreiroa, J.P., Infante, J.M., Monturiol, J.M., Cuervo, M.: Indicaciones de la laparostomia de cremallera. Cir. Urg.2:160, 1987
Duff, J.H.: Septic shock and multiple organ failure. In Surgical Infection in Critical Care Medicine, J.L. Meakins, editor, New York, Churchill Livingstone, 1985, p. 95
Ranson, J.H.C.: Etiological and prognostic factors in human acute pancreatitis: A review. Am. J. Gastroenterol.77:633, 1982
Clavien, P.A., Hanser, H., Meyer, P., Rohner, A.: Value of contrast-enhanced computerized tomography in the early diagnosis and prognosis of acute pancreatitis: A prospective study of 202 patients. Am. J. Surg.155:457, 1988
Becker, V.: Pathological anatomy and pathogenesis of acute pancreatitis. World J. Surg.5:303, 1981
Castaneda Fernandez, L., Ayensa Rincon, A., Grau Carmona, T., Cuesta Valentin, M.A., Chames Vaisman, M.A., Doblas Dominguez, M.: Pancreatitis aguda de mala evolucion: Laparostomia secuencial de desbridamiento. Soporte intensivo en UMI. Informe preliminar. Medicina Intensiva6:203, 1987
Stephen, M., Loewenthal, J.: Generalized infective peritonitis. Surg. Gynecol. Obstet.147:231, 1978
Fry, D.E., Garrison, R.N., Heitsch, R.C., Calhoun, K., Polk, H.C.: Determinants of death in patients with intra-abdominal abscess. Surgery88:517, 1980
Stricker, P.D., Hunt, D.R.: Surgical aspects of pancreatic abscess. Br. J. Surg.73:644, 1986
McKenna, J.P., Currie, D.J., McDonald, J.A.: The use of continuous postoperative peritoneal lavage in the management of diffuse peritonitis. Surg. Gynecol. Obstet.130:254, 1970
Stephen, M., Loewenthal, J.: Continuing peritoneal lavage in high risk peritonitis. Surgery85:603, 1979
Jennings, W.C., Wood, C.D., Guernsey, J.M.: Continuous postoperative lavage in the treatment of peritoneal sepsis. Dis. Colon Rectum25:641, 1982
Garcia Sabrido, J.L., Quintans, A., Polo, J.R., Perez Ferreiroa, J., Canales, C., Tellado, J.M.: Lavado peritoneal postoperatorio continuo (LPPC) en peritonitis de alto riesgo (PAR). Cir. Esp.34:73, 1985
Champault, G., Magnier, M., Psalmon, F., Patel, J.C.: Discussion en cours: La non fermeture parietale dans la chirurgie iterative des peritonitis. Chirurgie105:508, 1979
Hay, J.M., Duchatelle, P., Elman, A., Flamant, Y., Maillard, J.N.: Les ventres laisses ouverts. Chirurgie105:508, 1979
Dupre, A., Frere, G., Guignier, M., Peralta, J.L.: Evisceration therapeutique controlee lor des peritonitis dites depassees. Nouv. Presse Med.40:3257, 1979
Steinberg, D.: On leaving the peritoneal cavity open in acute generalized suppurative peritonitis. Am. J. Surg.137:216, 1979
Fagniez, P.L., Hay, J.M., Regnier, B., Maillare, J.N., Julien, M., Germain, A., Elman, A.: Les peritonitis “depassees.” Attitude therapeutique et resultats. Nouv. Presse Med.8:1348, 1979
Duff, J.H., Moffat, J.: Abdominal sepsis managed by leaving abdomen open. Surgery90:774, 1981
Doutre, L.P., Perissat, J., Saric, J.: La laparostomie. Method d'exception dans le traitement des peritonites gravissimes. Ann. Chir.36:433, 1982
Broomé, A., Hansson, L., Lundgren, F., Smedberg, S.: Open treatment of abdominal septic catastrophes. World J. Surg.7:792, 1983
Anderson, E.D., Mandelbaum, D.M., Ellison, E.C., Carey, L.C., Cooperman, M.: Open packing of the peritoneal cavity in generalized bacterial peritonitis. Am. J. Surg.145:131, 1983
Bradley, E.L., Fulenwider, J.T.: Open treatment of pancreatic abscess. Surg. Gynecol. Obstet.159:509, 1984
Goris, R.J.A.: Ogilvie's method applied to infected wound disruption. Arch. Surg.115:1103, 1980
Guivarc'h, M., Roullet-Audy, J.C., Chapmann, A.: La non-fermeture parietale dans la chirurgie iterative des peritonites. Chirurgie105:287, 1979
Schein, M., Saadia, R., Decker, GAG.: The open management of the septic abdomen. Surg. Gynecol. Obstet.163:587, 1986
Penninckx, F.M., Kerremans, R.P., Lauwers, P.M.: Planned relaparotomies in the surgical treatment of severe generalized peritonitis from intestinal origin. World J. Surg.7:762, 1983
Trede, M., Linder, M.M., Wesch, G.: Die indikation zur relaparotomie bei postoperativer peritonitis. Langenbecks Arch. Chir.352:295, 1980
Dellinger, E.P.: Wertz, M.J., Meakins, J.L., Solomkin, J.S., Allo, M.D., Howard, R.J., Simmons, R.L.: Surgical infection stratification system from intra-abdominal infection: Multicenter trial. Arch. Surg.120:21, 1985
Bohnen, J., Boulanger, M., Meakins, J.L., McLean, P.H.: Prognosis in generalized peritonitis: Relation to cause and risk factors. Arch. Surg.118:285, 1983
Meakins, J.L., Solomkin, J.S., Allo, M.D.: A proposed classification of intraabdominal infections. Stratification of etiology and risk for future therapeutic trials. Arch. Surg.119:1372, 1984
Elebute, E.A., Stoner, H.B.: The grading of sepsis. Br. J. Surg.70:29, 1983
Wouters, D.B., Krom, R.A.F., Sloof, M.J.H., Kootstra, G., Kuijers, J.: The use of Marlex mesh in patients with generalized peritonitis and multiple organ system failure. Surg. Gynecol. Obstet.156:609, 1983
Schein, M., Saadia, R., Jamieson, J.R., Decker, G.A.G.: The “sandwich technique” in the management of the open abdomen. Br. J. Surg.73:369, 1986
Boyd, W.C.: Use of Marlex mesh in acute loss of the abdominal wall due to infection. Surg. Gynecol. Obstet.144:251, 1977
Stone, H.H., Fabian, T.C., Turkelson, M.L., Jurkiewicz, M.J.: Management of acute full-thickness losses of the abdominal wall. Ann. Surg.193:612, 1981
Leguit, Jr., P.: Zip closure of the abdomen. Netherlands J. Surg.34:40, 1982
Stone, H.H., Strom, P.R., Mullins, R.J.: Pancreatic abscess management by subtotal resection and packing. World J. Surg.8:340, 1984
Pichlmayer, R., Lehr, L., Pahlow, J., Guthy, E.: Postoperative kontinuierliche offene dorsoventrale bauchspulung bei schweren formen der peritonitis. Chirurg54:299, 1983
Garcia Sabrido, J.L., Tellado, J.M., Quintans, A., Polo, J.R., Ferreiroa, J.P., Infante, J.M., Monturiol, J.M., Romero, A.: Pancreatitis necrotizante: Cierre temporal del abdomen con cremalleras. Cir. Esp.16:341, 1987
Garcia Sabrido, J.L., Tellado, J.M., Christou, N.V., Polo, J.R., Valdecantos, E.: Treatment of severe intra-abdominal sepsis and/or necrotic foci by an “open-abdomen” approach. Zipper and Zipper mesh techniques. Arch. Surg.123:152, 1988
Teichmann, W., Eggert, A., Witmann, D.H., Bocker, W.: Der reisverschluss als neue methode des temporaren bauchdecken Verschlusses in der abdominal chirurgie. Chirurg56:173, 1985
Teichmann, W., Witmann, D.H., Andreone, P.A.: Scheduled reoperations (etappen lavage) for diffuse peritonitis. Arch. Surg.121:147, 1986
Editorial: Tratamiento abierto del abdomen séptico. Lancet (Spanish edition) 9:431, 1986
Goekas, M.C., Baltaxe, H.A., Banks, P.A., Silva, J., Frey, C.F.: Acute pancreatitis. Davis Conference. Ann. Intern. Med.103:86, 1985
White, T.T.: Acute pancreatitis: Surgical Aspects. In The Pancreas. Principles of Medical and Surgical Practice, L.H. Toledo-Pereyra, editor, New York, Wiley Medical Publication, 1985, p. 207
Beger, H.G., Buchler, M., Bittner, R., Block, S., Nevalainen, T., Roscher, R.: Necrosectomy and postoperative local lavage in necrotizing pancreatitis. Br. J. Surg.75:207, 1988
Foster, P.D., Ziffren, S.E.: Severe acute pancreatitis. Arch. Surg.85:252, 1962
Frey, C.F.: Hemorrhagic pancreatitis. Am. J. Surg.137:616, 1979
Wall, A.J.: Peritoneal dialysis in the treatment of severe acute pancreatitis. Med. J. Austral.2:281, 1965
Rosato, E.F., Mullis, W.F., Rosato, F.E.: Peritoneal lavage therapy in hemorrhagic pancreatitis. Surgery74:106, 1973
Kivilaakso, E., Lempinen, M., Makelainen, A., Nikki, P., Schroeder, T.: Pancreatic resection versus peritoneal lavation for acute fulminant pancreatitis. Ann. Surg.199:426, 1984
Imrie, C.W.: Leading article: Peritoneal lavage in severe acute pancreatitis. Br. J. Surg.72:677, 1985
Stone, H.H., Fabian, T.C.: Peritoneal dialysis in the treatment of acute alcoholic pancreatitis. Surg. Gynecol. Obstet.150:878, 1980
Lawson, D.W., Dagget, W.H., Civetta, J.M.: Surgical treatment of acute necrotizing pancreatitis. Ann. Surg.172:605, 1970
Hollender, L.F., Meyer, C., Marrie, A., da Silva, E., Costa, J.: Garcia Castellanos, J.: Role of surgery in the management of acute pancreatitis. World J. Surg.5:361, 1981
Norton, L., Eiseman, B.: Near total pancreatectomy for hemorrhagic pancreatitis. Am. J. Surg.127:191, 1974
Aldridge, M.C., Ornstein, M., Glazer, G., Dudley, H.A.: Pancreatic resection for severe acute pancreatitis. Br. J. Surg.72:796, 1985
Alexandre, J.H., Guerreri, M.T.: Role of total pancreatectomy in the treatment of necrotizing pancreatitis. World J. Surg.5:369, 1982
Nicholson, M.L., McMortensen, N.J., Espiner, H.J.: Pancreatic abscess: Results of prolonged irrigation of the pancreatic bed after surgery. Br. J. Surg.75:88, 1988
Richards, W.O., Scorill, W., Shin, B., Reed, W.: Acute renal failure associated with increased intra-abdominal pressure. Ann. Surg.197:183, 1983
Bohnen, J.M.A., Mustard, R.A., Oxholm, S.E., Schouten, A.: APACHE II score and abdominal sepsis. A prospective study. Arch. Surg.123:225, 1988
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Cuesta, M.A., Doblas, M., Casta∼neda, L. et al. Sequential abdominal reexploration with the zipper technique. World J. Surg. 15, 74–80 (1991). https://doi.org/10.1007/BF01658968
Issue Date:
DOI: https://doi.org/10.1007/BF01658968