Sekonder genel peritonitlerde mortalite ve morbiditeye etkili faktörler 88 vakalık çok değişkenli analiz

Abstract

SUMMARY In this prospective study, we evaluated factors effecting morbidity and mortality in secondary generalized peritonitis. The study was done at Dicle University Hospital in 88 patients with diagnosis of secondary peritonitis and undergone an emergency operation. All patients were admitted in our surgical department and followed up. Pre prepared form was filled for all patients and patients admitted to intensive care unit postoperatively. Data were evaluated for age (over 65 years or less), sex, complaint at admission, duration of complaints, findings of abdominal paracentesis, labaratory findings such as heamatocritis, white blood cell counts and platelets, presence of radiological findings such as free air in upright abdominal graphy and free intraperitoneal fluids in ultrasonograpy, time passed from the start of symptoms to operation, pre operative antibiotic prophylacsia, prophylacsia for deep vein thrombosis, at the end of the study and operative diagnosis, presence of contamination, and source of sepsis. Postoperative complications, day of staying in intensive care unit, results of treatment, the worst scores of Meinhaim Peritonitis Index (MPI) and Acute Physiology And Chronic Health Evaluation (APACHE II) recorded at first 24 hours of operation were alll recorded. All patients were treated with Secondary generalized peritonitis protochol. Peptic ulser perforation, perforated appendicitis and small bowel perforations were most common reasons of secondary peritonitis. Meinhaim Peritonitis Index and APACHE II scores could be used in the follow up of critical patient although both scores were not well accepted as important and serious scores for showing mortality and morbidity. Although count of cultured bacteria was not high enough to make statistical significance, mortality rate was higher in culture positive cases. Statistical significance was found between patients less or equel to 64 (6/70) and over 64 (7/18) years of age and age was only independent variable affecting mortality. Our mortality rate was 14.8 % and it was one of the lowest mortality in the literature. Morbidity rate was 38.6% and increased day of intensive care was affecting morbidity. Sensivity of paracentesis and ultrasonography were 60.25 % and 44.3 1 % respectively. As a conclusion, age was significantly increasing mortality. Sucsessfully made control of septic source decreased mortality. Our clinical protochol or secondary peritonitis was sucsesfüll. 31ÖZET Sekonder genel peritonitlerde mortaliteye ve morbiditeye etkili faktörleri inceleyen bu prospektif çalışmada Dicle Üniversitesi Hastanesi Genel Cerrahi Kliniğince Nisan 2004-Mart 2005 tarihleri arasında acilden alınıp ameliyat esnasında sekonder genel peritonit tanısı konan olgular dahil edildi. Çalışmaya dahil edilen olgulara önceden hazırlanan form doldurularak hastanede kaldığı sürece takibe alındı. Çalışma bitiminde formdaki bilgiler değerlendirmeye alınıp yaş, cinsiyet, başvurudaki şikayetler ve süresi, parasentez bulguları, ayakta direk batın grafisinde serbest hava, ultrasonografide batında serbest sıvı varlığı, semptomların başlamasından ameliyata kadar geçen süre, ameliyat öncesi antibiyotik proflaksisi, derin ven trombozu proflaksisi, ameliyat esnasında ise tanı, yapılan ameliyat şekli, septik kaynak kontrolü ve kültür sonucu değerlendirildi Ayrıca ameliyatın süreside kaydedildi. Ameliyat sonrası komplikasyonlar, yoğun bakımda kalış süreleri, tedavi sonucumuz, Manheim peritonit indeksi ve Acute Physiology And Chronic Health Evaluation II skorları kaydedildi. Hastaların hepsine sekonder genel peritonit tedavisi uygulandı. Bu çalışmada toplam 88 olgu sekonder genel peritonit nedeniyle öpere edildi, yaş ortalaması 44,2 yıldır(15-94), 28(%31,8)'i kadın, 60(%68,2)'ı erkek idi. Erkek/Kadın oram ise 2.1 idi. Ortalama yaş kadınlarda 43,2(16-80), erkeklerde 44,7(15-94) idi. Yapılan analizlerde 13(ort yaş:60.5)'ü mortal seyretmişti, 60 erkek olgudan 8'i, 28 kadın olgudan 5'i mortal seyretti. 65 yaş ve üstü 18 olgudan7'si, 64 yaş ve altı 70 olgudan 6'sı mortal seyretmişti. Sekonder genel peritonitlerde peptik ülser perforasyonu (%46.6), perfore apandisit (%27.3) ve ince barsak perforasyonu (%11.4) etyolojide en sık sorumlu etkenlerdi. Parasentezin tamdaki sensitivitesini %60.25, USG nin sensitivetisini %44.31 idi. Morbiditeyi %38.6 olarak tespit ettik ve morbiditeye etkili tek bağımsız değişkeni ise yoğun balamda kalış süresinin uzaması olarak tespit ettik(P<0.005). 65 yaş üstü ve 64 yaş ve altı olgularımız arasındaki mortalite farkı belirgindi ve mortaliteyi açıklamaktaki anlamlı tek bağımsız değişkenin yaşlılık olduğunu saptadık(P<0.005). Total mortalitemiz %14.8 gibi bir değerle literatürde belirtilenlerin alt sınırında bulduk. Manheim peritonit indeksi ve Acute Physiology And Chronic Health Evaluation II skoru sekonder genel peritonitlerde mortaliteyi açıklamakta anlamlı bulunmadı. Yüksek skorlu hastaların bile uygun tedavi, yeterli yoğun bakım şartlan ve iyi bir medikal destek ile yaşatılabileceği gösterilmiştir. Ancak bu tür hastaları tanımlamada ortak bir dil oluşturması ve kritik hastaların belirlenmesinde kullanılabileceği görüşündeyiz. 29

SUMMARY in this prospective study, we evaluated factors effecting morbidity and mortality in secondary generalized peritonitis. The study was done at Dicle University Hospital in 88 patients with diagnosis of secondary peritonitis and undergone an emergency operation. Ali patients were admitted in our surgical department and followed up. Pre prepared form was fîlled for ali patients and patients admitted to intensive çare unit postoperatively. Data were evaluated for age (över 65 years ör less), sex, complaint at admission, duration of complaints, findings of abdominal paracentesis, labaratory findings such as heamatocritis, white blood celi counts and platelets, presence of radiological findings such as free air in upright abdominal graphy and free intraperitoneal fluids in ultrasonograpy, time passed from the start of symptoms to operation, pre operative antibiotic prophylacsia, prophylacsia for deep vein thrombosis, at the end of the study and operative diagnosis, presence of contamination, and source of sepsis. Postoperative complications, day of staying in intensive çare unit, results of treatment, the worst scores of Meinhaim Peritonitis Index (MPI) and Acute Physiology And Chronic Health Evaluation (APACHEII) recorded at first 24 hours of operation were alil recorded. Ali patients were treated with Secondary generalized peritonitis protochol. Peptic ülser perforation, perforated appendicitis and small bowel perforations were most common reasons of secondary peritonitis. Meinhaim Peritonitis Index and APACHE II scores could be used in the follow up of critical patient although both scores were not well accepted as important and serious scores for showing mortality and morbidity. Although count of cultured bacteria was not high enough to make statistical significance, mortality rate was higher in culture positive cases. Statistical significance was found between patients less ör equel to 64 (6/70) and över 64 (7/18) years of age and age was only independent variable affecting mortality. Our mortality rate was 14.8 % and it was öne of the lowest mortality in the literatüre. Morbidity rate was 38.6% and increased day of intensive çare was affecting morbidity. Sensivity of paracentesis and ultrasonography were 60.25 % and 44.31 % respectively. As a conclusion, age was significantly increasing mortality. Sucsessfiılly made control of septic source decreased mortality. Our clinical protochol ör secondary peritonitis was sucsesfiıll. 31