Dietmar H. Wittmann
Medical College of Wisconsin
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Annals of Surgery | 1996
Dietmar H. Wittmann; Moshe Schein; Robert E. Condon
OBJECTIVE The authors review current definition, classification, scoring, microbiology, inflammatory response, and goals of management of secondary peritonitis. SUMMARY BACKGROUND DATA Despite improved diagnostic modalities, potent antibiotics, modern intensive care, and aggressive surgical treatment, up to one third of patients still die of severe secondary peritonitis. Against the background of current understanding of the local and systemic inflammatory response associated with peritonitis, there is growing controversy concerning the optimal antibiotic and operative therapy, intensified by lack of properly conducted randomized studies. In this overview the authors attempt to outline controversies, suggest a practical clinical approach, and highlight issues necessitating further research. METHODS The authors review the literature and report their experience. RESULTS The emerging concepts concerning antibiotic treatment suggest that less-in terms of the number of drugs and the duration of treatment-is better. The classical single operation for peritonitis, which obliterates the source of infection and purges the peritoneal cavity, may be inadequate for severe forms of peritonitis; for the latter, more aggressive surgical techniques are necessary to decompress increased intra-abdominal pressure and prevent or treat persistent and recurrent infection. The widespread acceptance of the more aggressive and demanding surgical methods has been hampered by the lack of randomized trials and reportedly high associated morbidity rates. CONCLUSIONS Sepsis represents the hosts systemic inflammatory response to bacterial peritonitis. To improve results, both the initiator and the biologic consequences of the peritoneal infective-inflammatory process should be addressed. The initiator may be better controlled in severe forms of peritonitis by aggressive surgical methods, whereas the search for methods to abort its systemic consequences is continuing.
Journal of Trauma-injury Infection and Critical Care | 1990
Charles Aprahamian; Dietmar H. Wittmann; Jack M. Bergstein; Edward J. Quebbeman
Planned relaparotomy (temporary abdominal closure) was studied prospectively in 20 trauma patients. Four died in the first 24 hours from hypothermia, coagulopathy, shock (three), and septic shock (one). The 16 survivors had a Velcro-like prosthetic placed to facilitate abdominal closure and re-entry. Prosthetic was necessary in eight because bowel edema precluded fascial closure, and useful for removal of packing (three) and for the management of peritonitis (five). The prosthetic did not open spontaneously, nor was it associated with evisceration or bowel fistula. Temporary abdominal closure (TAC) permitted reappraisal and staged repair of intra-abdominal pathology, including bowel resection and anastomosis. TAC identified 14 problems early: bleeding (five), bile leaks (two), GI complications (six), liver necrosis (one). Five patients developed superficial wound infections, and three went on to develop fascial necrosis.
Surgery | 1996
Moshe Shein; Dietmar H. Wittmann; Réne Holzheimer; Robert E. Condon
BACKGROUND Although the proximal role of systemic cytokines in the infectious-inflammatory cascades is well recognized, the magnitude and meaning of its intraperitoneal levels in peritonitis have received little attention. We hypothesized that in peritonitis a significant and clinically relevant cytokine-mediated inflammatory response is compartmentalized in the peritoneal cavity. METHODS MEDLINE was used to search the literature for all articles dealing with experimental, primary, and secondary bacterial peritonitis and cytokines. RESULTS Bacterial peritonitis is associated with an immense intraperitoneally compartmentalized cytokine response, with plasma levels of cytokines representing only the tip of the iceberg. Although certain amount of cytokines may be beneficial to the peritoneal defense mechanisms, higher levels correlate with adverse outcome. Thus it is plausible to look at acute peritonitis as initially a combined infective (microorganism) and inflammatory (cytokines) process. The clinical significance of the distinction between peritoneal inflammation and infection and the relevance of our findings to the stratification and treatment of peritonitis are discussed. CONCLUSIONS Current surgical and antibiotic therapy for peritonitis is able to clear the peritoneal cavity of infective concentration of bacteria, but many patients continue to die of an uncontrolled activation of the inflammatory cascade. We suggest that one potential venue for therapeutic progress is the modulation of the compartmentalized peritoneal inflammatory response.
Journal of Trauma-injury Infection and Critical Care | 1995
Kirk A. Ludwig; Edward J. Quebbeman; Jack M. Bergstein; James R. Wallace; Dietmar H. Wittmann; Charles Aprahamian
Ischemic complications associated with hemorrhagic shock after blunt or penetrating trauma can result in acute renal, pulmonary, or hepatic failure. Less well described is the association between hemorrhagic shock and ischemic necrosis of the right colon, with only 14 cases reported in the literature. Herein, we report three previously healthy young trauma victims with shock-associated right colon necrosis. Each patient suffered a period of hypotension after injury. Diagnosis and operation took place within 2 days of initial injury in all three cases. In each patient, a right colectomy and primary anastomosis was performed without complication. Pathologic examination of the resected specimens showed ischemic necrosis, but no evidence of vascular thrombosis or embolic occlusion of the mesenteric vessels. The etiology of this type of ischemic colitis is not clear, but seems to represent a form of nonocclusive mesenteric ischemia. Knowledge of this disease process will lead to early recognition, prompt treatment, and a satisfactory outcome.
Infection | 1998
Dietmar H. Wittmann
SummaryThe basic principles for treating intraabdominal infections are fourfold. (1) to obliterate the infectious source; (2) to purge bacteria and toxins; (3) to maintain organ system function and (4) to tame the inflammatory process. Operative and nonoperative treatment options are available. Operative therapy includes different strategies: (1) the standard operation; (2) advanced procedures to decompress the abdominal compartment syndrome and (3) percutaneous drainage of abscesses. Nonoperative management includes: (1) antibiotic therapy; (2) hemodynamic and pulmonary support; (3) nutrition and metabolic support; (4) detoxification support (including support of renal and hepatic function) and (5) inflammation modulating therapy. Standard operative management addresses the first two principles and has been shown to reduce mortality by more than 50%. A recent extensive series of studies reports mortality rates around 20%. Patients with an abdominal compartment syndrome (intraabdominal pressure over 25 torr) and patients with advanced disease and compounding risk factors best documented by high APACHE-II scores are candidates for more advanced operations. The mortality rate following abdominostomy (leaving the abdomen open) in 869 patients participating in 37 studies was 42%, when the abdomen was simply left open for decompression (open abdominostomy). When a mesh was used to cover the abdominal wound (mesh abdominostomy) 39% of 439 patients enrolled in 12 studies died. Patients who underwent staged abdominal repair (STAR abdominostomy) faired better. Of 385 patients in 11 studies 28% died. Data from antibiotic studies as well as from immunomodulating therapy are nonconclusive at this point with respect to reducing mortality in intraabdominal infection.The basic principles for treating intraabdominal infections are fourfold. (1) to obliterate the infectious source; (2) to purge bacteria and toxins; (3) to maintain organ system function and (4) to tame the inflammatory process. Operative and nonoperative treatment options are available. Operative therapy includes different strategies: (1) the standard operation; (2) advanced procedures to decompress the abdominal compartment syndrome and (3) percutaneous drainage of abscesses. Nonoperative management includes: (1) antibiotic therapy; (2) hemodynamic and pulmonary support; (3) nutrition and metabolic support; (4) detoxification support (including support of renal and hepatic function) and (5) inflammation modulating therapy. Standard operative management addresses the first two principles and has been shown to reduce mortality by more than 50%. A recent extensive series of studies reports mortality rates around 20%. Patients with an abdominal compartment syndrome (intraabdominal pressure over 25 torr) and patients with advanced disease and compounding risk factors best documented by high APACHE-II scores are candidates for more advanced operations. The mortality rate following abdominostomy (leaving the abdomen open) in 869 patients participating in 37 studies was 42%, when the abdomen was simply left open for decompression (open abdominostomy). When a mesh was used to cover the abdominal wound (mesh abdominostomy) 39% of 439 patients enrolled in 12 studies died. Patients who underwent staged abdominal repair (STAR abdominostomy) faired better. Of 385 patients in 11 studies 28% died. Data from antibiotic studies as well as from immunomodulating therapy are nonconclusive at this point with respect to reducing mortality in intraabdominal infection.
Diseases of The Colon & Rectum | 1995
Moshe Schein; Ahmad Assalia; Samuel Eldar; Dietmar H. Wittmann; Ronald Lee Nichols
The necessity of preoperative or intraoperative mechanical bowel preparation of the colon, before primary anastomosis, has been recently challenged in clinical elective and emergency situations. PURPOSE: This experimental study in dogs investigated the safety of segmental resection and primary anastomosis in the unprepared or loaded colon. METHODS: Two segments of the descended colon were resected and anastomosed in each animal. Group I (12 anastomoses) received preoperative mechanical bowel preparation; the colon was not prepared in Group II (16 anastomoses); in Group III (12 anastomoses), a preliminary distal colonic obstruction was produced, and during the subsequent resection the colon was loaded. Postoperatively, animals were observed clinically, and anastomoses were assessed at autopsy on the ninth day. RESULTS: All animals recovered uneventfully. At autopsy there was no evidence of anastomotic leakage. CONCLUSIONS: In light of recent clinical reports and this experimental study, the ritual of mechanical bowel preparation should be further scrutinized.
Infection | 1991
Dietmar H. Wittmann; Robert E. Condon
SummaryThe antibiotic most appropriate for prophylaxis of postoperative infections depends on the nature of the operation. In aseptic (clean) operations, grampositive postoperative infections are the primary concern, and cefazolin is recommended because of its excellent pharmacokinetics and good activity against grampositive pathogens, including staphylococci. In those operations where violation of the digestive tract creates a contaminated field, a cefotaxime-generation cephalosporin is the agent of choice because of the excellent safety profiles and the capability of agents of this class to kill essentially all pathogenic gram-negative aerobes as well as a substantial portion of anaerobes. Selection of resistant bacteria has not been significant and is unlikely to become so with single-dose prophylaxis. Occasionally, if there is a high probability that the operative field may be heavily contaminated by anaerobes, metronidazole should be added. Dosing should be sufficient to cover the operative period. Only a single prophylactic dose is necessary, given at the time of induction of anesthesia. For particularly long operations, a second dose of those antibiotics with half-lives shorter than 60 min is required two hours after the first. Single-injection prophylaxis is effective, inexpensive, has no side effects and does not induce bacterial resistance.ZusammenfassungDie Art der Operation bestimmt die Wahl des besten Antibiotikums zur Prophylaxe post-operativer Infektionen. Infektionen nach aseptischen Operationen werden vorwiegend durch grampositive Bakterien verursacht, und wir empfehlen Cefazolin zur Prophylaxe, weil es gut grampositive Kokken, einschließlich der Staphylokokken, eliminiert und außerdem aus pharmakokinetischer Sicht hervorragend zur Prophylaxe geeignet ist. Bei Operationen mit Kontamination der Operationswunde durch Darmbakterien nach Magen-Darm-Eröffnung, sind Cephalosporine der Cefotaxim-Generation Mittel der Wahl, da sie alle wichtigen gramnegativen aeroben und wesentliche Teile der obligat anaeroben Bakterien erfassen und da mit der Einzeldosierung Nebenwirkungen äußerst selten sind. Die Selektion primär resistenter Bakterien durch die Einzeldosierung ist nicht beobachtet worden und unwahrscheinlich. Starke Kontamination des Operationsfeldes durch obligate Anaerobier erfordert die gleichzeitige Verabreichung von Metronidazol. Die Dosierung soll ausreichend sein, um genügend hohe Konzentrationen in der Operationswunde zu realisieren. Die bei Operationseinleitung verabreichte Einzeldosis hat die besten Resultate. Dauern die Operationen extrem lange, ist eine zweite Dosis zwei Stunden nach der ersten indiziert, falls das Antibiotikum eine kurze Eliminationshalbwertzeit von weniger als 60 Minuten hat. Die Einzeldosisprophylaxe ist wirksam, billig, hat keine Nebenwirkungen und induziert keine bakertielle Resistenz.
Infection | 1991
Dietmar H. Wittmann; Jack M. Bergstein; Constantine T. Frantzides
SummaryIn acute life-threatening surgical infections requiring immediate institution of antimicrobial therapy before bacteriological results are available, antibiotic treatment must be empiric. For best efficacy a more sophisticated form of empiric therapy is offered, termed calculated antibiotic therapy (CAT). Calculated antibiotic therapy requires consideration of a) typical bacterial spectrum; b) bacterial pathogenicity and synergism; c) antibacterial concentrations at the site of infection; d) toxicity and adverse effects; e) interaction with immune response; and f) results of properly conducted trials. Intraabdominal infections are used as an example here to assess the efficacy of clinically used cephalosporins and penicillins for determination of calculated antibiotic therapy. CAT identifiesEscherichia coli andBacteroides fragilis as the most important pathogens for intraabdominal infections and determines the most effective antibiotics at the tissue breakpoint, which is defined as the minimal concentration maintained for more than 90% of the dosage interval period at the infected tissues. At the tissue breakpoint calculated antibiotic therapy identifies cefotaximegeneration cephalosporins to be fully (100%) active against the most important aerobic pathogenE. coli and metronidazole as fully active against the important obligate anaerobeB. fragilis. Calculated antibiotic therapy becomes relatively important, since impeccably controlled clinical therapeutic trials as a foundation for therapy are rarely published.ZusammenfassungDie Therapie akuter lebensbedrohlicher chirurgischer Infektionen erfordert eine empirische initiale antimikrobielle Chemotherapie. Die kalkulierte antimikrobielle Chemotherapie (CAT) kann als eine Verbesserung der rein empirischen Therapie betrachtet werden. Sie erfordert, daß folgende Kriterien berücksichtigt werden: 1. Typisches Spektrum der Infektionserreger, 2. Pathogenität der Bakterien und deren infektiogener Synergismus, 3. Konzentrationen des Antibiotikums am Ort der Infektion, 4. Nebenwirkungen, 5. Störungen der Immunabwehr, 6. Ergebnisse sauberer kontrollierter klinischer Studien. Am Beispiel der intraabdomionalen Infektionen wird die Leistungsfähigkeit der CAT mit klinisch wichtigen Penicillinen und Cephalosporinen untersucht. Die CAT identifiziertEscherichia coli undBacteroides fragilis als die wichtigsten Infektionserreger der bakteriellen Peritonitis. nach CAT wird ein Tissue-Breakpoint als die Konzentration definiert, die während 90% des Dosisintervals am Ort der Infektion realisiert bleibt. Die effektivsten Antibiotika nach CAT sind Cefotaxim-Generation Cephaloporine, durch die 100% allerE. coli Bakterien (n=10413) am Gewebe-Breakpoint erfaßt werden und Metronidazol, durch das 100% aller obligaten Anaerobier der SpeziesB. fragilis (n=2345) bei Gewebe-Breakpoint Konzentrationen erfaßt werden. CAT gewinnt an Bedeutung, weil sich gezeigt hat, daß kontrollierte Studien mit Antibiotika nur selten qualitativ ausreichende Informationen enthalten, um als Therapiegrundlage verwertet werden zu können.
Diagnostic Microbiology and Infectious Disease | 1995
Charles Aprahamian; Moshe Schein; Dietmar H. Wittmann
To assess the efficacy of cefotaxime in the treatment of severe intra-abdominal infections, we reviewed the bacteriology of secondary peritonitis and evaluated the efficacy of cefotaxime and metronidazole in 79 patients undergoing staged abdominal repair. We were able to demonstrate that the combination of an aggressive surgical policy with an effective antimicrobial regimen eliminates pathogens from the previously infected peritoneal cavity. Additional improvement in results awaits further advances in supportive care and/or methods to reverse the cascades of the excessive inflammatory or cytokine responses.
Infection | 1991
Charles Aprahamian; Dietmar H. Wittmann
SummarySurgical principles in the management of intraabdominal infection have remained constant. Rather, it is the application of these principles in selected cases that has varied. Judgment, therefore, becomes paramount for the surgeon. In selected cases multiple planned relaparotomies may be the most effective means of closing the infectious source and eliminating toxic infectious materials. The Burr has proven to be an effective yet safe means of permitting entry and closure of the abdominal fascia.ZusammenfassungDie Prinzipien der Behandlung intraabdomineller Infektionen sind unverändert geblieben. Was veränderlich ist, sind die Anwendungen dieser Prinzipien in ausgewählten Fällen. Die Beurteilung des jeweiligen Falles ist daher für den Chirurgen von herausragender Bedeutung. In ausgewählten Fällen kann die vorher geplante mehrfache Eröffnung des Bauchraumes die effektivste Methode sein, den Infektionsherd zu verschließen und toxisches, infektiöses Material zu entfernen. Der Klettverschluß (Burr) hat sich als eine wirkungsvolle und sichere Methode erwiesen, die Bauchhöhle zu eröffnen und zu verschließen.