Vol. 67, No. 3
233
Peritonitis - Prevention And Treatment EARL BELLE SMITH, M.D., EA.C.S., St. Francis Hospital, Pittsburgh, Pennsylvania
Since 1966, the utilization of intraperitoneal cephalothin (Keflin) as adjuvant therapy experimentally and clinically in the prevention and management of localized and generalized peritonitis has been most rewarding. Today, bacterial peritonitis remains a serious complication of spontaneous, traumatic and/or iatrogenic gastro-intestinal perforations, inflammatory and neoplastic diseases of the stomach, large and small intestines and solid and hollow intra-abdominal organs. During the past six years intermittent intraperitoneal sump drainage has been a complementary factor in the prevention of localized accumulations of intraperitoneal and retroperitoneal exudates. The present article reports reactions of test dogs with intestinal resections and intraperitoneally administered cephalothin in addition to intermittent intraperitoneal sump drainage and our clinical evaluation of 202 patients with localized and generalized peritonitis who were given adjuvant therapy. ....
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with single-layered open anastomoses. Three of the 12 dogs were used for controls and received no therapy. All test dogs received two to four grams of Cephalin intraperitoneally daily and intermittent intraperitoneal sump drainage for 10 days. All of the dogs survived the 30-day observation period; however, two of the three control animals demonstrated evidence of peritonitis. Two dogs were sacrificed after 30 days and pathological examinations demonstrated gross and histological evidence of localized and generalized peritonitis. A 3 mm. anastomotic leak was noted in one dog. CLINICAL EVALUATION
During an eight year period (1966-1974), 202 patients admitted with generalized or localized peritonitis of six to 40 hours were given sodium cephalothin intraperitoneally and intraperitoneal sump drainage after numerous operative procedures. The latter consisted of closures of gastro-intestinal and visceral perforations and gastro-intestinal resections. Supplementary antibiotics including, cephalothin, garramycin (Gentamicin) and clindomycin (Cleocin) were administered intramuscularly and intravenously.
Fig. 1 Ambro sump with Penrose drain.
METHODS
Cephalothin (Keflin) is a cephalosporin antibiotic with a wide range of effectiveness, low toxicity and high resistance to the enzyme penicillinase. A Davol-Abramson all-purpose drain, No. 3574, length 18 inches, or an ampro sump (Shirley) with attached 1/2 inch Penrose drains (Fig. 1), are adequate lowsuction sump drainage techniques.
At the termination of the required operative procedures two or three 18 inch all-purpose drains with attached 1/2 inch penrose drains were placed into the pelvic cavity, right and left colic gutters. The drains were placed near, but not on or at the anastomotic sites. One hundred mls. of a 1% cephalothinnormal saline solution was administered two to four times daily for 10 days. Two hours of intermittent low sump suction was utilized three times daily. The latter was commenced approximately four hours after the intraperitoneal cephalin administration which al-
ANIMAL EXPERIMENTS
Twelve mongrel dogs weighing between 12 and 22 kilograms had approximately two inch segmental small and large bowel resections
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
234
lows adequate time for local and systemic antibiotic activity. The duration of therapy was variable, depending upon the severity of the peritonitis, nature of the disease processes and the clinical course of the patients. All intestinal anastomoses cases had continuous adjuvant therapy for 10 days. Bacteriologic analyses were conducted on all peritoneal exudates prior to the start of definitive treatment and adjuvant therapy. RESULTS
Successful recovery occurred in 195 of 202 patients. In seven patients, peritonitis was fatal. Table. 1. BACTERIOLOGICAL ANALYSES
NO. OF CASES
ORGANISMS E. Coli Aerobacter aerogenes Streptococci Pseudomonas aeruginosa Clostridia Proteus Bacteroides TOTAL
149 86 78 42 21 18 12 406
Other antibiotics, particularly, cephalothin, clindomycin (Cleocin) and garramycin (Gentamicin), were administered intramuscularly or intravenously when necessary. There were 16 demonstrative anastomotic leaks in this series of cases. Normally, the peritoneum has numerous functions, e.g., secretion and absorption. However, the damaged peritoneum has defective absorptive and secretive powers and the sump drainage assists in exudate clearance from various recesses of the peritoneal cavity. Thus, intraperitoneal abscesses may be prevented and small anastomotic leaks allowed to heal more effectively
MAY, 1975
and spontaneously. Some of the bacteriological reports demonstrated two or more organisms, and the most frequently isolated from the peritoneal exudates were Escherichia coli, Aerobacter aerogenes, streptococci and Pseudomonas aeruginosa (Table 1). DISCUSSION
Previous reports'-3 have substantiated the effectiveness of intraperitoneal antibiotics and this aforementioned technique revealed adequate gastro-intestinal function, no evidences of respiratory depression, intraperitoneal adhesions, or other adverse effects previously reported in the literature with intraperitoneal antibiotics. Our continuous series of 202 patients with localized and generalized peritonitis, who were treated with adjuvant therapy, had seven deaths or a mortality of 3.3%. Adjuvant therapy consisted of intraperitoneally administered cephalothin supplemented with other parenteral antibiotics in addition to intermittent intraperitoneal lowsuction dump drainage. It is my conclusion that adjuvant therapy which consisted of intraperitoneal 1% Cephalothin solution, additive parenteral antibiotics and intraperitoneal sump drainage is of inestimable value and of great importance in the maintenance of satisfactory mortalitymorbidity statistics in these serious cases of generalized and localized peritonitis. LITERATURE CITED
1. SMITH, E.B. Adjuvant Therapy of Generalized Peritonitis with Intraperitoneally Administered Cephalothin. Surg., Gynec. & (Obstets., 136, 441:443, 1973. 2. SMITH, E.B. Intraperitoneal Cephalothin as Adjuvant Therapy in Peritonitis. Jour. Nat. Med. Assoc., 14, 109:111, 1972. 3. SMITH, E.B. Protection of Intestinal Anastomoses. Surg. Advances, June, 1962.
(Collins, from page 220) SUMMARY
The Craig needle biopsy technique, employed to obtain specimens from the vertebral body, is a safe method when used by a radiologist under fluoroscopic guidance. Percutaneous biopsy of vertebral bodies was performed successfully in 62 patients. Specimens were obtained from the cervical spine,
thoracic, lumbar and sacral spine. The diagnoses rendered ranged from benign to malignant lesions. LITERATURE CITED
1. HANAFEE, R.N. and P.L. TOBIN, Radiology,
92:605-606, 1969. 2. OTTOLENGHI, C.E., Jour. Bone Joint Surg., 51A:1531-1544, 1969.
233
Peritonitis - Prevention And Treatment EARL BELLE SMITH, M.D., EA.C.S., St. Francis Hospital, Pittsburgh, Pennsylvania
Since 1966, the utilization of intraperitoneal cephalothin (Keflin) as adjuvant therapy experimentally and clinically in the prevention and management of localized and generalized peritonitis has been most rewarding. Today, bacterial peritonitis remains a serious complication of spontaneous, traumatic and/or iatrogenic gastro-intestinal perforations, inflammatory and neoplastic diseases of the stomach, large and small intestines and solid and hollow intra-abdominal organs. During the past six years intermittent intraperitoneal sump drainage has been a complementary factor in the prevention of localized accumulations of intraperitoneal and retroperitoneal exudates. The present article reports reactions of test dogs with intestinal resections and intraperitoneally administered cephalothin in addition to intermittent intraperitoneal sump drainage and our clinical evaluation of 202 patients with localized and generalized peritonitis who were given adjuvant therapy. ....
-------....
with single-layered open anastomoses. Three of the 12 dogs were used for controls and received no therapy. All test dogs received two to four grams of Cephalin intraperitoneally daily and intermittent intraperitoneal sump drainage for 10 days. All of the dogs survived the 30-day observation period; however, two of the three control animals demonstrated evidence of peritonitis. Two dogs were sacrificed after 30 days and pathological examinations demonstrated gross and histological evidence of localized and generalized peritonitis. A 3 mm. anastomotic leak was noted in one dog. CLINICAL EVALUATION
During an eight year period (1966-1974), 202 patients admitted with generalized or localized peritonitis of six to 40 hours were given sodium cephalothin intraperitoneally and intraperitoneal sump drainage after numerous operative procedures. The latter consisted of closures of gastro-intestinal and visceral perforations and gastro-intestinal resections. Supplementary antibiotics including, cephalothin, garramycin (Gentamicin) and clindomycin (Cleocin) were administered intramuscularly and intravenously.
Fig. 1 Ambro sump with Penrose drain.
METHODS
Cephalothin (Keflin) is a cephalosporin antibiotic with a wide range of effectiveness, low toxicity and high resistance to the enzyme penicillinase. A Davol-Abramson all-purpose drain, No. 3574, length 18 inches, or an ampro sump (Shirley) with attached 1/2 inch Penrose drains (Fig. 1), are adequate lowsuction sump drainage techniques.
At the termination of the required operative procedures two or three 18 inch all-purpose drains with attached 1/2 inch penrose drains were placed into the pelvic cavity, right and left colic gutters. The drains were placed near, but not on or at the anastomotic sites. One hundred mls. of a 1% cephalothinnormal saline solution was administered two to four times daily for 10 days. Two hours of intermittent low sump suction was utilized three times daily. The latter was commenced approximately four hours after the intraperitoneal cephalin administration which al-
ANIMAL EXPERIMENTS
Twelve mongrel dogs weighing between 12 and 22 kilograms had approximately two inch segmental small and large bowel resections
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
234
lows adequate time for local and systemic antibiotic activity. The duration of therapy was variable, depending upon the severity of the peritonitis, nature of the disease processes and the clinical course of the patients. All intestinal anastomoses cases had continuous adjuvant therapy for 10 days. Bacteriologic analyses were conducted on all peritoneal exudates prior to the start of definitive treatment and adjuvant therapy. RESULTS
Successful recovery occurred in 195 of 202 patients. In seven patients, peritonitis was fatal. Table. 1. BACTERIOLOGICAL ANALYSES
NO. OF CASES
ORGANISMS E. Coli Aerobacter aerogenes Streptococci Pseudomonas aeruginosa Clostridia Proteus Bacteroides TOTAL
149 86 78 42 21 18 12 406
Other antibiotics, particularly, cephalothin, clindomycin (Cleocin) and garramycin (Gentamicin), were administered intramuscularly or intravenously when necessary. There were 16 demonstrative anastomotic leaks in this series of cases. Normally, the peritoneum has numerous functions, e.g., secretion and absorption. However, the damaged peritoneum has defective absorptive and secretive powers and the sump drainage assists in exudate clearance from various recesses of the peritoneal cavity. Thus, intraperitoneal abscesses may be prevented and small anastomotic leaks allowed to heal more effectively
MAY, 1975
and spontaneously. Some of the bacteriological reports demonstrated two or more organisms, and the most frequently isolated from the peritoneal exudates were Escherichia coli, Aerobacter aerogenes, streptococci and Pseudomonas aeruginosa (Table 1). DISCUSSION
Previous reports'-3 have substantiated the effectiveness of intraperitoneal antibiotics and this aforementioned technique revealed adequate gastro-intestinal function, no evidences of respiratory depression, intraperitoneal adhesions, or other adverse effects previously reported in the literature with intraperitoneal antibiotics. Our continuous series of 202 patients with localized and generalized peritonitis, who were treated with adjuvant therapy, had seven deaths or a mortality of 3.3%. Adjuvant therapy consisted of intraperitoneally administered cephalothin supplemented with other parenteral antibiotics in addition to intermittent intraperitoneal lowsuction dump drainage. It is my conclusion that adjuvant therapy which consisted of intraperitoneal 1% Cephalothin solution, additive parenteral antibiotics and intraperitoneal sump drainage is of inestimable value and of great importance in the maintenance of satisfactory mortalitymorbidity statistics in these serious cases of generalized and localized peritonitis. LITERATURE CITED
1. SMITH, E.B. Adjuvant Therapy of Generalized Peritonitis with Intraperitoneally Administered Cephalothin. Surg., Gynec. & (Obstets., 136, 441:443, 1973. 2. SMITH, E.B. Intraperitoneal Cephalothin as Adjuvant Therapy in Peritonitis. Jour. Nat. Med. Assoc., 14, 109:111, 1972. 3. SMITH, E.B. Protection of Intestinal Anastomoses. Surg. Advances, June, 1962.
(Collins, from page 220) SUMMARY
The Craig needle biopsy technique, employed to obtain specimens from the vertebral body, is a safe method when used by a radiologist under fluoroscopic guidance. Percutaneous biopsy of vertebral bodies was performed successfully in 62 patients. Specimens were obtained from the cervical spine,
thoracic, lumbar and sacral spine. The diagnoses rendered ranged from benign to malignant lesions. LITERATURE CITED
1. HANAFEE, R.N. and P.L. TOBIN, Radiology,
92:605-606, 1969. 2. OTTOLENGHI, C.E., Jour. Bone Joint Surg., 51A:1531-1544, 1969.
