Authors:
Joseph Forrester, Luke Caddell, Renceh Flojo

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Background: Enterocutaneous (EC) fistulae are a significant complication of abdominal surgery. The surgical takedown of EC fistulae carries a high risk of complications, including sepsis, recurrence, and mortality. Identifying biomarkers to detect complications early may improve outcomes. C-reactive protein (CRP), a marker of inflammation and tissue injury, has shown promise in predicting anastomotic leaks in colorectal surgery. This study evaluates the utility of postoperative CRP declination curves in detecting leaks after EC fistula takedown.
Methods: This retrospective case series analyzed adult patients undergoing EC fistula takedown performed by a single surgeon at our institution over the past three years. Inclusion required documented EC fistulae, failure of nonoperative management, and at least three postoperative high-sensitivity CRP measurements. CRP, white blood cell (WBC) and temperature trends were analyzed alongside secondary outcomes: fistula recurrence, hospital stay, and complications.
Results: Seven of 15 eligible cases met inclusion criteria. CRP levels peaked immediately postoperatively and on average declined in patients without leaks, stabilizing by the second postoperative week. In patients with leaks, CRP levels deviated from this pattern, remaining elevated until managed. While WBC counts and temperatures showed variable trends, CRP demonstrated more consistent correlations with postoperative recovery and complications.
Conclusion: High-sensitivity CRP may serve as a useful adjunct for early detection of postoperative leaks following EC fistula takedown. Preliminary findings support further prospective studies to validate CRP declination curves as a diagnostic tool, potentially improving monitoring and patient outcomes in this high-risk population.

Authors:
Alisher Okhunov, Dilshod Qorikhonov, Shokhista Bobokulova

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Background. Widespread purulent peritonitis is one of the leaders topping the list of causes of death in abdominal surgery, reaching up to 30%. However, in the context of the development of sepsis and multiple organ failure, mortality can reach 90%.
Methods. In the Department of Surgical Infection of the Multidisciplinary Clinic of the Tashkent Medical Academy, from 2021 to 2024, 58 patients with widespread purulent peritonitis were treated and examined. The causes of peritonitis were destructive appendicitis (8.6%), perforation of gastric and duodenal ulcers (6.9%), acute destructive cholecystitis (5.2%), infected forms of pancreatic necrosis (19%), abdominal injuries with damage to internal organs (22.4%), inflammatory diseases of the female genital organs (3.4%), malignant tumours of the intestine complicated by perforation of the intestinal wall (34.5%). General clinical, laboratory and instrumental research methods were used. Therapeutic measures included: laparostomy, total nasointestinal intubation, abdominal vacuum therapy, antibacterial and detoxification therapy.
Results. Out of 58 patients, recovery was in 43.1% of cases. Mortality was noted in 56.9% of cases (33 patients). Among the deceased patients, 78.8% did not undergo vacuum therapy due to the onset of death in the early stages after their admission to our clinic or after the application of a controlled laparostomy (up to 48 hours after surgery). The highest cause of mortality was progressive peritonitis, with the development of abdominal sepsis and multiple organ failure.
Conclusions. The use of controlled laparostomy in the treatment of widespread purulent peritonitis improves the results of surgical intervention, which is accompanied by a decrease in the frequency of postoperative complications and deaths.

Authors:
Alisher Okhunov, Dilshod Qorikhonov, Shokhista Bobokulova

Body of Abstract:
Background. The evolutionarily developed and genetically determined protective response of the organism in the form of an urgent adaptation syndrome for the preservation of vital functions at the proper physiological level in several cases may turn out to be untenable, which puts the body on the verge of a functional breakdown, followed by irreversible disintegration of organ functions, leading to death or severe functional disorders. The resulting condition, manifested by various clinical syndromes, is called extreme for the need for practical surgery.
Methods. We analyzed the causes of death in 82 patients with necrotizing fasciitis type 2. 53 patients were male, and 29 were female. The medical history data, the features of the development and course of the disease, and the causes of death were analyzed.
Results. To the greatest extent, the concept of an extreme condition corresponded to the clinical course of necrotizing fasciitis type 2 with the development of infectious-toxic shock syndrome (100%), proceeding at lightning speed and ending in death in the first 3 days. The development of an extreme condition in the majority of patients with necrotizing fasciitis (87.8%) did not have a causal relationship with any severe underlying disease, which in itself could create a precedent of functional failure. Often, there were also no manifestations of the infectious beginning, the focus that initiates fasciitis. Microbial invasion, which was not always recorded, was usually associated with abrasions (31.7%), abrasions on the skin (24.4%) or banal wounds (18.3%), including surgical (6.1%), contusions (11%) or post-injection infiltrates and abscesses (8.5%).
Conclusions. The acute onset of the disease with the catastrophic development of severe endotoxicosis and functional disintegration form the basis of the condition, which is designated by the concept of “extreme”. At the same time, we cannot exclude the possibility of a torpid course of the disease with a prodromal period due to the accumulation of a critical concentration of the toxin in the bloodstream and the implementation of a generalized septic process, the clinical manifestations of which then become violent.

Authors:
Cheryl Ernst

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Diabetes and variations in glucose control are comorbidities that increase complications in the surgical patient (Harris, 2018). Insulin signaling is impaired during surgery and transient insulin resistance develops. Decreased circulating insulin levels lead to a physiological hyperglycemic response that lasts 24 to 48 hours after surgery. Surgeries involving the chest and abdomen have a longer and more pronounced degree of hyperglycemia reaction in the body (Peacock, 2019). The prevalence of surgical site infections (SSIs) in surgical patients across the United States has gained significant attention as preventable healthcare infections from the Centers for Disease Control and Prevention (CDC) in recent years. A stratified list supporting this evidence was published by the CDC in 1999 titled Prevention of Surgical Site Infection and is the accepted practice guideline for preventing SSIs (Berrios-Torres et al., 2017). The CDC directs surgical specialties to reduce perioperative glycemic control protocol targets to less than 200 mg/dl for all surgical patients to reduce SSIs (Sermkasemskin et al., 2022). Similar evidence-based guidelines were published by the World Health Organization (WHO) and the American College of Surgeons (ACS) (Camperlengo et al., 2023). Nearly six years after these strong guidelines were published, there is still limited evidence that SSI prevention activities are being followed (Camperlengo et al., 2023).
Intraoperative stress hyperglycemia is underestimated because of its presumed lower incidence rate compared to diabetes. The rise in patients presenting to surgical facilities with impaired fasting glucose and/or insulin resistance varies from 23 to 60%. The nationwide increase in SSI rates is also leading to decreasing reimbursement rates and third-party payer denials. This warrants the re-evaluation of treatment standards and the updating of evidence-based protocols (Karimian, 2018).
Stress hyperglycemia is summarized as increased glycogenolysis, insulin resistance, and excessive gluconeogenesis in response to neuroendocrine triggers of stress stimulated by the hypothalamic-pituitary-adrenal axis, sympathoadrenal system receptors, and proinflammatory cytokines. The cytokines are tumor necrosis factor-α, interleukin (IL)-1, and IL-6 (Sermkasemsin et al., 2022). Risk factors for stress hyperglycemia include unknown diabetes, a high American Society of Anesthesiologists (ASA) risk score, long surgical duration, blood transfusion, and intraoperative hypotension (Sermkasemskin et al., 2022).
The purpose of this prospective study was to reduce postoperative complications by expanding perioperative glucose monitoring and treatment during surgical procedures lasting over two (2) hours. By treating stress hyperglycemia, the hypothesis is that a statistically significant decrease in postoperative complications will be observed by evaluating outcomes with the Comprehensive Complication Index (Peacock, 2019).

Authors:
Christian Potter, Dow Stough MD, Tom Ashfield

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Intra-Incisional Delivery
The delivery of microdoses of incisional antibiotics to reduce the rate of surgical site infections has been documented in the literature for over 40 years.3,4,5 There is now robust evidence and published meta-analysis to change treatment guidelines in this area. A meta-analysis demonstrated significantly less surgical site infections versus placebo in a study by Mourad.1There are multiple antibiotics involving a variety of classes which potentially could be distributed by the intra-incisional route.
The benefits of a direct deposit of antibiotics into the surgical area include the following:
1. The administration of the preoperative antibiotics can be tailored to the onset of the surgical procedure. Specifically, the intra-incisional antibiotic can be given with a lidocaine diluent 10 to 15 minutes prior to the surgical procedure. The uncertainty of the oral and intravenous routes can be eliminated.
2. The nausea associated with oral administration of antibiotics is no longer a concern.
3. The major organ systems of the body, including the CNS, are not exposed to large amounts of unneeded antibiotics along with the associated adverse events.
4. The normal gastrointestinal microbiota is not altered detrimentally. The emergence of colitis due to Clostridium should be minimized by an intra-incisional approach.
5. Higher tissue levels with greater efficacy are possible with intra-incisional delivery compared to other routes.
6. There is less risk to the patient of medical errors and mishaps involving IV access, mixing of antibiotic solutions, and proper calculation of the intravenous rate of delivery.
7. The development of resistant organisms will be minimized with the intra-incisional route.
8. Compliance issues with oral antibiotics will be eliminated.
9. There is a theoretical possibility to decrease systemic drug interactions by the intra-incisional approach.
10. Current antibiotic recommendations are based primarily on efficacy and safety not on cost. Cost savings could be an additional benefit realized through the intra-incisional route of antibiotic delivery.
11. There is an emerging trend reported by the National Nosocomial Infections Surveillance System (NNIS), that demonstrates gram-negative bacilli decreased from 56% to 33% over the last 25 years. Gram-positive bacteria have increased in prevalence. Surgical site infections caused by staph aureus have increased by 30%. The resistant strains of staph and MRSA, compromise almost 50% of this group. The antibiotics needed to treat this MRSA, are often those that cannot be given orally, and therefore intravenous treatment is recommended. The intra-incisional route offers the advantage of soft tissue antibiotic delivery for the treatment or prevention of MRSA without the requirement for IV access.